Provider Demographics
NPI:1104972371
Name:CLYNES, SUSAN G (LCSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:G
Last Name:CLYNES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 FLAIR DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-2604
Mailing Address - Country:US
Mailing Address - Phone:214-226-0667
Mailing Address - Fax:214-357-2240
Practice Address - Street 1:8350 MEADOW RD STE 272
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0334
Practice Address - Country:US
Practice Address - Phone:214-226-0667
Practice Address - Fax:214-357-2240
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S71YMedicare ID - Type Unspecified