Provider Demographics
NPI:1023085750
Name:KOTOWICZ, SUSAN T (MSW, LCSW, ACSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:T
Last Name:KOTOWICZ
Suffix:
Gender:F
Credentials:MSW, LCSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 MAXWELL AVE
Mailing Address - Street 2:CHEYENNE
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2215 MAXWELL AVE
Practice Address - Street 2:CHEYENNE
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3849
Practice Address - Country:US
Practice Address - Phone:307-634-6142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY0541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY305303OtherBS OF WY
WY305303OtherBS OF WY