Provider Demographics
NPI:1265976625
Name:MACINTYRE, SUSAN M
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:MACINTYRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 W PORTOBELLO AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-8345
Mailing Address - Country:US
Mailing Address - Phone:520-416-4395
Mailing Address - Fax:
Practice Address - Street 1:739 W PORTOBELLO AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-8345
Practice Address - Country:US
Practice Address - Phone:520-416-4395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT191381041C0700X
AZ181221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical