Healthcare Provider Details

I. General information

NPI: 1053377689
Provider Name (Legal Business Name): SUSAN K MARCUM LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 06/10/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 STATE ROUTE 107
GALLIPOLIS OH
45631-8243
US

IV. Provider business mailing address

PO BOX 390
HUNTINGTON WV
25708-0390
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-4600
  • Fax: 740-446-2944
Mailing address:
  • Phone: 304-429-1088
  • Fax: 304-696-1623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS0022219
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: