Basic Information
| Provider Information | |||||||||
| NPI: | 1134116502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENNIGE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | HELEN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1602 E. SELTICE WAY | ||||||||
| Address2: | SUITE D | ||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086190190 | ||||||||
| FaxNumber: | 2086190190 | ||||||||
| Practice Location | |||||||||
| Address1: | 1602 E SELTICE WAY | ||||||||
| Address2: | SUITE D | ||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838547082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086190190 | ||||||||
| FaxNumber: | 2086190195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 06/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW - 1136 | ID | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LW 00008547 | WA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 8940571 | 01 | WA | L&I CRIME VICTIMS | OTHER |