Provider Demographics
NPI:1679975635
Name:AMORY, SUSAN BLAKE (CSW, LPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:BLAKE
Last Name:AMORY
Suffix:
Gender:F
Credentials:CSW, LPC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:BLAKE
Other - Last Name:PRENDERGRAST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW
Mailing Address - Street 1:1914 THOMES AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3527
Mailing Address - Country:US
Mailing Address - Phone:307-631-9931
Mailing Address - Fax:307-635-7706
Practice Address - Street 1:300 E 17TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001
Practice Address - Country:US
Practice Address - Phone:307-631-9931
Practice Address - Fax:307-635-7706
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2351041C0700X
WY1725101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical