Provider Demographics
NPI:1902310790
Name:ST VRAIN, SUSAN ELIZABETH (MA)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:ST VRAIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14218 HARBOUR PL
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-8008
Mailing Address - Country:US
Mailing Address - Phone:502-407-9737
Mailing Address - Fax:
Practice Address - Street 1:990 VILLA ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94041-1236
Practice Address - Country:US
Practice Address - Phone:502-407-9737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2025-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006159101YM0800X
KY101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor