Provider Demographics
NPI:1740509744
Name:RECORD, SUSAN NASSER (LPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:NASSER
Last Name:RECORD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3117 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-6458
Mailing Address - Country:US
Mailing Address - Phone:208-640-6814
Mailing Address - Fax:
Practice Address - Street 1:1323 E SHERMAN AVE
Practice Address - Street 2:STE D
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4069
Practice Address - Country:US
Practice Address - Phone:208-676-1075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-01
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4090101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor