Healthcare Provider Details

I. General information

NPI: 1023085750
Provider Name (Legal Business Name): SUSAN T KOTOWICZ MSW, LCSW, ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 03/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 MAXWELL AVE CHEYENNE
CHEYENNE WY
82001-3849
US

IV. Provider business mailing address

2215 MAXWELL AVE CHEYENNE
CHEYENNE WY
82001-3849
US

V. Phone/Fax

Practice location:
  • Phone: 307-634-6142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number054
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: