Provider Demographics
NPI:1043384886
Name:STOCKMAN, SUSANNE BETH (LPCC)
Entity type:Individual
Prefix:MS
First Name:SUSANNE
Middle Name:BETH
Last Name:STOCKMAN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 MONTEZUMA AVE # 937
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2626
Mailing Address - Country:US
Mailing Address - Phone:505-690-1346
Mailing Address - Fax:505-820-6863
Practice Address - Street 1:1807 2ND ST
Practice Address - Street 2:SUITE 20
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3499
Practice Address - Country:US
Practice Address - Phone:505-690-1346
Practice Address - Fax:505-820-6863
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0070951101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04386591Medicaid