Provider Demographics
NPI:1396964458
Name:HADLEY, SUSANH CHAPPLE (TCM)
Entity type:Individual
Prefix:MRS
First Name:SUSANH
Middle Name:CHAPPLE
Last Name:HADLEY
Suffix:
Gender:F
Credentials:TCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 26 STREET
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-9946
Mailing Address - Country:US
Mailing Address - Phone:801-625-3652
Mailing Address - Fax:
Practice Address - Street 1:237 26 STREET
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-9946
Practice Address - Country:US
Practice Address - Phone:801-625-3652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTCERTIFIEDCASEMANAGER171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000308007Medicaid