Basic Information
| Provider Information | |||||||||
| NPI: | 1528177524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIRKSEY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LPCC, LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 832 MCKINLEY AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447032463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304559407 | ||||||||
| FaxNumber: | 3304558706 | ||||||||
| Practice Location | |||||||||
| Address1: | 832 MCKINLEY AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447032463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304559407 | ||||||||
| FaxNumber: | 3304558706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YA0400X | 933673 | OH | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | E0002415 | OH | X | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.