Provider Demographics
NPI:1740430610
Name:BAILEY, SUSAN J (LADC I)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
Last Name:BAILEY
Suffix:
Gender:F
Credentials:LADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 717
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:NH
Mailing Address - Zip Code:03574-0717
Mailing Address - Country:US
Mailing Address - Phone:603-869-2210
Mailing Address - Fax:603-869-2355
Practice Address - Street 1:GROVE STREET
Practice Address - Street 2:15 GROVE STREET
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860
Practice Address - Country:US
Practice Address - Phone:603-869-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA809101YA0400X
NH0570101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)