Provider Demographics
NPI:1922333418
Name:ROUGGLY, SUSAN M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:ROUGGLY
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 1:2822 RIVERS BND S
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-3906
Mailing Address - Country:US
Mailing Address - Phone:573-358-0541
Mailing Address - Fax:
Practice Address - Street 1:2822 RIVERS BND S
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-3906
Practice Address - Country:US
Practice Address - Phone:573-358-0541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070251091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical