Provider Demographics
NPI:1548371198
Name:KENNEY-NOZISKA, SUEANN GAYLE (LISW)
Entity type:Individual
Prefix:
First Name:SUEANN
Middle Name:GAYLE
Last Name:KENNEY-NOZISKA
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 EL MOLINO BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2915
Mailing Address - Country:US
Mailing Address - Phone:575-524-9157
Mailing Address - Fax:575-524-5968
Practice Address - Street 1:350 EL MOLINO BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2915
Practice Address - Country:US
Practice Address - Phone:575-524-9157
Practice Address - Fax:575-524-5968
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 203391041C0700X
NMI-066361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical