Provider Demographics
NPI:1124350749
Name:FORKUS, SUSAN L (LCPC)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:L
Last Name:FORKUS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15
Mailing Address - Street 2:201 SOUTH MAIN STREET
Mailing Address - City:BRYANT POND
Mailing Address - State:ME
Mailing Address - Zip Code:04219-0015
Mailing Address - Country:US
Mailing Address - Phone:207-665-2616
Mailing Address - Fax:
Practice Address - Street 1:201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BRYANT POND
Practice Address - State:ME
Practice Address - Zip Code:04219-6431
Practice Address - Country:US
Practice Address - Phone:207-665-2616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-06
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1048101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional