Provider Demographics
NPI:1265624100
Name:MACOMB, SUSAN K (LCPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:MACOMB
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S 11TH AVE, STE 402A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-242-2335
Mailing Address - Fax:208-242-2344
Practice Address - Street 1:500 S 11TH AVE, STE 402A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4880
Practice Address - Country:US
Practice Address - Phone:208-242-2335
Practice Address - Fax:208-242-2344
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3891101YP2500X
IDLCPC-6826101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional