Provider Demographics
NPI:1013314079
Name:GARRETT, SUSAN WIBERG (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:WIBERG
Last Name:GARRETT
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 1:2101 S. BLACKHAWK ST.
Mailing Address - Street 2:SUITE 240
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1475
Mailing Address - Country:US
Mailing Address - Phone:720-449-6764
Mailing Address - Fax:720-532-0219
Practice Address - Street 1:2101 S. BLACKHAWK ST.
Practice Address - Street 2:SUITE 240
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1475
Practice Address - Country:US
Practice Address - Phone:720-449-6764
Practice Address - Fax:720-532-0219
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9930241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62575023Medicaid