Healthcare Provider Details

I. General information

NPI: 1013927664
Provider Name (Legal Business Name): SUZANNE DARLENE GREENE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUZANNE WHITE LCSW

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 MOUNTAIN VIEW RD
RAPID CITY SD
57702-2520
US

IV. Provider business mailing address

PO BOX 3022
CUSTER SD
57730
US

V. Phone/Fax

Practice location:
  • Phone: 605-791-4665
  • Fax: 605-791-4666
Mailing address:
  • Phone: 207-649-4047
  • Fax: 605-673-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3178
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC7959
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1013927664
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: