Provider Demographics
NPI:1386880664
Name:SHAFER, SUSAN PASSAFIUME (LCMHC, LCAS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:PASSAFIUME
Last Name:SHAFER
Suffix:
Gender:F
Credentials:LCMHC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 RANDELL PKWY WILMINGTON NC 28403
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2829
Mailing Address - Country:US
Mailing Address - Phone:910-791-5719
Mailing Address - Fax:910-799-8180
Practice Address - Street 1:5010 RANDELL PKWY WILMINGTON NC 28403
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2829
Practice Address - Country:US
Practice Address - Phone:910-791-5719
Practice Address - Fax:910-799-8180
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1892101YA0400X
NC7254101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104090Medicaid