Provider Demographics
NPI:1821176801
Name:GIDDENS, SUJETTE EVITT (LCSW)
Entity Type:Individual
Prefix:
First Name:SUJETTE
Middle Name:EVITT
Last Name:GIDDENS
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 1:925 NORTH MERRIMAC DR
Mailing Address - Street 2:P O BOX 767
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750
Mailing Address - Country:US
Mailing Address - Phone:229-423-8080
Mailing Address - Fax:
Practice Address - Street 1:334 TIFTON ELDORADO ROAD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794
Practice Address - Country:US
Practice Address - Phone:229-386-3494
Practice Address - Fax:229-386-3221
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0036991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBGMMMedicare PIN