Healthcare Provider Details

I. General information

NPI: 1205910460
Provider Name (Legal Business Name): SUSAN G HALLETT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 VIRGINIA ST 200-A
URBANNA VA
23175-2438
US

IV. Provider business mailing address

PO BOX 1042
URBANNA VA
23175-1042
US

V. Phone/Fax

Practice location:
  • Phone: 804-758-4242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904005105
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: