Provider Demographics
NPI:1104095967
Name:BIGELOW, SUSAN V (MS, LAC, LCAS)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:V
Last Name:BIGELOW
Suffix:
Gender:F
Credentials:MS, LAC, LCAS
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:VIRGINIA
Other - Last Name:BIGELOW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:705 S MANGUM ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3904
Mailing Address - Country:US
Mailing Address - Phone:919-683-1607
Mailing Address - Fax:
Practice Address - Street 1:705 S MANGUM ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3904
Practice Address - Country:US
Practice Address - Phone:919-683-1607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO64101YA0400X
NC2054101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112351Medicaid