1730257767 NPI number — SUSAN MARIE REDDICK DOUB M.A.ED.,LPC

Table of content: SUSAN MARIE REDDICK DOUB M.A.ED.,LPC (NPI 1730257767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730257767 NPI number — SUSAN MARIE REDDICK DOUB M.A.ED.,LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUB
Provider First Name:
SUSAN
Provider Middle Name:
MARIE REDDICK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.ED.,LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730257767
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3602 LIME ROCK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27011-8152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-251-1008
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3447 ROBINHOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27106-4701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-830-5558
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2006

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: 101YP2500X , with the licence number:  3753 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 3753 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6103227 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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