Provider Demographics
NPI:1639342066
Name:NATE, SUSAN R (LPC, PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:NATE
Suffix:
Gender:F
Credentials:LPC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 COUNTRY CLB STE 101
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9602
Mailing Address - Country:US
Mailing Address - Phone:307-382-6606
Mailing Address - Fax:307-382-9167
Practice Address - Street 1:263 COUNTRY CLB STE 101
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9602
Practice Address - Country:US
Practice Address - Phone:435-841-4060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY486101YM0800X
UT781141-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYNAT304951OtherBLUE CROSS BLUE SHIELD