Healthcare Provider Details

I. General information

NPI: 1558361527
Provider Name (Legal Business Name): SUSAN CAROL BAISDEN M.S.; PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN CAROL MARTIN

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 W 5TH AVE
WILLIAMSON WV
25661-3201
US

IV. Provider business mailing address

41 W 5TH AVE
WILLIAMSON WV
25661-3201
US

V. Phone/Fax

Practice location:
  • Phone: 304-235-3390
  • Fax: 304-235-3391
Mailing address:
  • Phone: 304-235-3390
  • Fax: 304-235-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number538
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number403
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCP00452669
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: