Basic Information
| Provider Information | |||||||||
| NPI: | 1750320230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ST. VILLE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PH.D., MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466161510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742886732 | ||||||||
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| Practice Location | |||||||||
| Address1: | 403 E MADISON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466172322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742831107 | ||||||||
| FaxNumber: | 5742831131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34005158A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.