Provider Demographics
NPI:1730202268
Name:POLLOCK, SUSAN D (LPCC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:POLLOCK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 JENNIFER ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-0947
Mailing Address - Country:US
Mailing Address - Phone:575-640-4715
Mailing Address - Fax:575-526-7112
Practice Address - Street 1:2990 N MAIN ST
Practice Address - Street 2:SUITE 3-A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1195
Practice Address - Country:US
Practice Address - Phone:505-524-1125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2625101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM50887343Medicaid