Provider Demographics
NPI:1942503529
Name:BOULDIN, SUSAN SMITH (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:SMITH
Last Name:BOULDIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1417 N SEMORAN BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-3555
Mailing Address - Country:US
Mailing Address - Phone:407-206-1106
Mailing Address - Fax:407-206-1112
Practice Address - Street 1:1417 N SEMORAN BLVD STE 203
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807
Practice Address - Country:US
Practice Address - Phone:407-206-1106
Practice Address - Fax:407-206-1112
Is Sole Proprietor?:No
Enumeration Date:2010-12-21
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 10109104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker