Provider Demographics
NPI:1760549687
Name:THIELE, SUSAN WAPNER (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:WAPNER
Last Name:THIELE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 NW 26TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-2871
Mailing Address - Country:US
Mailing Address - Phone:352-376-9706
Mailing Address - Fax:
Practice Address - Street 1:2521 NW 26TH PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-2871
Practice Address - Country:US
Practice Address - Phone:352-376-9706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW3127101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ5699OtherBLUE CROSS BLUE SHIELD