1497757090 NPI number — MS. SUSAN MARIE LILJEGREN MSSW, LCSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497757090 NPI number — MS. SUSAN MARIE LILJEGREN MSSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LILJEGREN
Provider First Name:
SUSAN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LILJEGREN
Provider Other First Name:
ZANN
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSSW, LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1497757090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
424 YELLOWSTONE AVE
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
CODY
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82414-9309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-578-2919
Provider Business Mailing Address Fax Number:
307-578-2920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
424 YELLOWSTONE AVE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
CODY
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82414-9309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-578-2919
Provider Business Practice Location Address Fax Number:
307-578-2920
Provider Enumeration Date:
08/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  35-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 614 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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