Provider Demographics
NPI:1750320230
Name:ST. VILLE, SUSAN M (PHD, MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:ST. VILLE
Suffix:
Gender:F
Credentials:PHD, MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46616-1510
Mailing Address - Country:US
Mailing Address - Phone:574-288-6732
Mailing Address - Fax:
Practice Address - Street 1:403 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2322
Practice Address - Country:US
Practice Address - Phone:574-283-1107
Practice Address - Fax:574-283-1131
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005158A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical