Provider Demographics
NPI:1215965744
Name:ROBERTS, SUSAN A (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 FORT SANDERS WEST BLVD
Mailing Address - Street 2:BUILDING 4 SUITE 205
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3351
Mailing Address - Country:US
Mailing Address - Phone:865-690-2395
Mailing Address - Fax:865-690-2396
Practice Address - Street 1:7424 MIDDLEBROOK PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-3109
Practice Address - Country:US
Practice Address - Phone:865-690-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000005811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3694557Medicare ID - Type UnspecifiedMEDICARE NUMBER