Provider Demographics
NPI:1528276631
Name:FONDRY, SUSAN WILLIAMSON (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:WILLIAMSON
Last Name:FONDRY
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:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:ROAN MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37687-0280
Mailing Address - Country:US
Mailing Address - Phone:423-928-4003
Mailing Address - Fax:423-772-3689
Practice Address - Street 1:600 E UNAKA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4035
Practice Address - Country:US
Practice Address - Phone:423-928-4003
Practice Address - Fax:423-772-3689
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSWL30441041C0700X
NCCOO20451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002879Medicaid
NC2863832CMedicare ID - Type Unspecified