Provider Demographics
NPI:1174613574
Name:SMITH, SUSAN BETTIS (LCP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:BETTIS
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:JEAN
Other - Last Name:ILIFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8001 COLLEGE BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210
Mailing Address - Country:US
Mailing Address - Phone:913-451-8550
Mailing Address - Fax:913-469-5266
Practice Address - Street 1:8001 COLLEGE BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210
Practice Address - Country:US
Practice Address - Phone:913-451-8550
Practice Address - Fax:913-469-5266
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS306103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS35976019OtherBCBS KC
MO35976019OtherBCBS KC