Provider Demographics
NPI:1396172599
Name:COUNTRYMAN, SUZANNAH GLOVER (EDS, LPES)
Entity type:Individual
Prefix:MISS
First Name:SUZANNAH
Middle Name:GLOVER
Last Name:COUNTRYMAN
Suffix:
Gender:F
Credentials:EDS, LPES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 RIVERS AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-4650
Mailing Address - Country:US
Mailing Address - Phone:843-343-1012
Mailing Address - Fax:
Practice Address - Street 1:7301 RIVERS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4650
Practice Address - Country:US
Practice Address - Phone:843-343-1012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
SC4662103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1588615918Medicaid