Provider Demographics
NPI:1427314814
Name:GALLENZ, SUSAN ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANN
Last Name:GALLENZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:WILLOW
Other - Middle Name:
Other - Last Name:GALLENZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:425 BERNICE PL
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-5301
Mailing Address - Country:US
Mailing Address - Phone:757-816-6899
Mailing Address - Fax:
Practice Address - Street 1:BLDG 404 B ST.
Practice Address - Street 2:CAMP PENDLETON VIRGINIA STATE MILITARY RESERVATION
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451
Practice Address - Country:US
Practice Address - Phone:757-961-6580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102081101YA0400X
VA09040067571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)