Provider Demographics
NPI:1205129640
Name:CHANDLER, SUZANNE MICHELE (LISW-S)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MICHELE
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:MICHELE
Other - Last Name:KEITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW-S
Mailing Address - Street 1:4464 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-5464
Mailing Address - Country:US
Mailing Address - Phone:513-649-8008
Mailing Address - Fax:513-649-8004
Practice Address - Street 1:4464 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45005-5464
Practice Address - Country:US
Practice Address - Phone:513-649-8008
Practice Address - Fax:513-649-8004
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0008038-SUPV1041C0700X, 101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0074946OtherMEDICAID LEGACY NUMBER
OH0074861OtherODADAS
OH01-0693OtherCARF CERTIFICATION
OHH208170OtherMEDICARE PTAN INDIVIDUAL