Provider Demographics
NPI:1194095521
Name:KICKLIGHTER, SUSAN RITA (MSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:RITA
Last Name:KICKLIGHTER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 MILLBROOK LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-2733
Mailing Address - Country:US
Mailing Address - Phone:386-547-9526
Mailing Address - Fax:
Practice Address - Street 1:749 MILLBROOK LN
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-2733
Practice Address - Country:US
Practice Address - Phone:386-547-9526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-02
Last Update Date:2012-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health