Provider Demographics
NPI:1144547498
Name:WILLI, SUELLEN MITZNER (LCSW)
Entity type:Individual
Prefix:
First Name:SUELLEN
Middle Name:MITZNER
Last Name:WILLI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2576 NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-9027
Mailing Address - Country:US
Mailing Address - Phone:541-479-1544
Mailing Address - Fax:
Practice Address - Street 1:2576 NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-9027
Practice Address - Country:US
Practice Address - Phone:541-479-1544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0025111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical