Provider Demographics
NPI:1730257767
Name:DOUB, SUSAN MARIE REDDICK (MAED,LPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE REDDICK
Last Name:DOUB
Suffix:
Gender:F
Credentials:MAED,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 LIME ROCK RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27011-8152
Mailing Address - Country:US
Mailing Address - Phone:336-251-1008
Mailing Address - Fax:
Practice Address - Street 1:3447 ROBINHOOD RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4701
Practice Address - Country:US
Practice Address - Phone:336-830-5558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3753101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103227Medicaid