Provider Demographics
NPI:1548911209
Name:FOX, SUSAN RICHELLE (LMSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:RICHELLE
Last Name:FOX
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 APACHE AVE
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2217
Mailing Address - Country:US
Mailing Address - Phone:208-709-3281
Mailing Address - Fax:
Practice Address - Street 1:101 E MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2017
Practice Address - Country:US
Practice Address - Phone:208-357-3104
Practice Address - Fax:888-990-2826
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-41675104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker