Provider Demographics
NPI:1942748199
Name:BIRD, SUZANNA MARIE
Entity type:Individual
Prefix:
First Name:SUZANNA
Middle Name:MARIE
Last Name:BIRD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUZY
Other - Middle Name:
Other - Last Name:BIRD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:675 ASPEN AVE
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:675 ASPEN AVE
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1414
Practice Address - Country:US
Practice Address - Phone:208-419-6196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID36378101YM0800X
1041C0700X
IDLCSW-433761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health