Healthcare Provider Details

I. General information

NPI: 1346843182
Provider Name (Legal Business Name): SUSSAN LEE GOLDSWORTHY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 07/12/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6811 BALLENGER RUN BLVD
FREDERICK MD
21703
US

IV. Provider business mailing address

4175 S. ALAMO AVE
TUCSON AZ
85707
US

V. Phone/Fax

Practice location:
  • Phone: 478-225-7590
  • Fax:
Mailing address:
  • Phone: 520-228-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number257763
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: