Provider Demographics
NPI:1215175542
Name:WILSON, SUSAN CLEMENT (MSC, MA, LGC, LMHC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CLEMENT
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSC, MA, LGC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 DULCE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-8284
Mailing Address - Country:US
Mailing Address - Phone:505-577-8480
Mailing Address - Fax:505-466-2183
Practice Address - Street 1:5 DULCE RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-8284
Practice Address - Country:US
Practice Address - Phone:505-577-8480
Practice Address - Fax:505-466-2183
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0118861101YM0800X
NMGC2009-012170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health