Provider Demographics
NPI:1639317548
Name:WUTTKE, SUSAN COLPITTS (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:COLPITTS
Last Name:WUTTKE
Suffix:
Gender:F
Credentials:LCSW
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 129
Mailing Address - Street 2:
Mailing Address - City:LAKEMONT
Mailing Address - State:GA
Mailing Address - Zip Code:30552-0003
Mailing Address - Country:US
Mailing Address - Phone:706-212-0195
Mailing Address - Fax:
Practice Address - Street 1:345 MANNING ROAD
Practice Address - Street 2:
Practice Address - City:LAKEMONT
Practice Address - State:GA
Practice Address - Zip Code:30552
Practice Address - Country:US
Practice Address - Phone:706-212-0195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0040671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical