Basic Information
| Provider Information | |||||||||
| NPI: | 1518165695 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COULTER | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | LCSW LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 296 W. SUNSET AVE | ||||||||
| Address2: | STE 15 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838158366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086660357 | ||||||||
| FaxNumber: | 2086660468 | ||||||||
| Practice Location | |||||||||
| Address1: | 296 W. SUNSET AVE | ||||||||
| Address2: | STE 15 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838158366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086660357 | ||||||||
| FaxNumber: | 2086660468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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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 | LW00009445 | WA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCSW-28136 | ID | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.