Healthcare Provider Details

I. General information

NPI: 1558576397
Provider Name (Legal Business Name): SUANNE TANEAL MASSEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1373
US

IV. Provider business mailing address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1373
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7758
  • Fax: 804-966-5639
Mailing address:
  • Phone: 757-314-7758
  • Fax: 804-966-5639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC004690
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: