Provider Demographics
NPI:1770655953
Name:SOULE, SUSAN BLACKWELL (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BLACKWELL
Last Name:SOULE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 ROUTE 1
Mailing Address - Street 2:SUITE 29C
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-4711
Mailing Address - Country:US
Mailing Address - Phone:207-846-0186
Mailing Address - Fax:
Practice Address - Street 1:500 ROUTE 1
Practice Address - Street 2:SUITE 29C
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-4711
Practice Address - Country:US
Practice Address - Phone:207-846-0186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC13241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM 5146Medicare ID - Type UnspecifiedLICENSED SOCIAL WORKER