Provider Demographics
NPI:1548543325
Name:KILLEEN, SUSAN C
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:C
Last Name:KILLEEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 NOTTINGHAM PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5540
Mailing Address - Country:US
Mailing Address - Phone:502-681-8622
Mailing Address - Fax:502-805-0656
Practice Address - Street 1:8300 NOTTINGHAM PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5540
Practice Address - Country:US
Practice Address - Phone:502-681-8622
Practice Address - Fax:502-805-0656
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2012-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY610101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional