Provider Demographics
NPI:1295801512
Name:ELAINE, SUSAN (MED, LMFT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ELAINE
Suffix:
Gender:F
Credentials:MED, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-439-8000
Mailing Address - Fax:423-439-2200
Practice Address - Street 1:LAKE DR.
Practice Address - Street 2:BUILDING 52
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:37684
Practice Address - Country:US
Practice Address - Phone:423-439-8000
Practice Address - Fax:423-439-2200
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN176106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN176OtherSTATE LICENSE
TN176OtherSTATE LICENSE