Provider Information for 1679975635
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SUSAN BLAKE AMORY CSW, LPC
Other Names:Former Name:SUSAN BLAKE PRENDERGRAST CSWSex: Female
NPI: 1679975635
Last Updated: 2018-07-31
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||||||
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| NPI | 1679975635 | ||||||||||||
| Enumeration Date | 2014-09-22 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | YES | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 1914 THOMES AVE CHEYENNE, WY 82001-3527 United States Phone: 307-631-9931 | Fax:307-635-7706 | ||||||||||||
| Primary Practice Address | 300 E 17TH ST CHEYENNE, WY 82001 United States Phone: 307-631-9931 | Fax:307-635-7706 | ||||||||||||
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