Provider Demographics
NPI:1306322383
Name:MAGOWAN-BLACK, SUSAN LEONETT (EDS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEONETT
Last Name:MAGOWAN-BLACK
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 SHUTTERLEE MILL RD
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401-1709
Mailing Address - Country:US
Mailing Address - Phone:540-332-3934
Mailing Address - Fax:540-332-3973
Practice Address - Street 1:1751 SHUTTERLEE MILL RD
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-1709
Practice Address - Country:US
Practice Address - Phone:540-332-3934
Practice Address - Fax:540-332-3973
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000207103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPPS-0600458OtherPUPIL PERSONNEL SERVICES
VA0813000207OtherSCHOOL PSYCHOLOGIST - LIMITED