MEDICARE: MS. SUSAN ANN GALLENZ LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	0710102081	VA
2	1041C0700X	Clinical Social Worker	0904006757	VA

General Provider Information

NPI Number	:	1427314814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN ANN GALLENZ LCSW

Provider Business Mailing Address
First Line	:	425 BERNICE PL
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-5301
Country	:	US
Telephone Number	:	757-816-6899
Fax Number	:

Provider Business Practice Location Address
First Line	:	BLDG 404 B ST.
Second Line	:	CAMP PENDLETON VIRGINIA STATE MILITARY RESERVATION
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451
Country	:	US
Telephone Number	:	757-961-6580
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2012
Last Update Date	:	04/10/2012

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