Provider Demographics
NPI:1043624406
Name:JULIEN, SUSAN ELAINE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELAINE
Last Name:JULIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103A CLUBHOUSE LN
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-8108
Mailing Address - Country:US
Mailing Address - Phone:513-313-8906
Mailing Address - Fax:513-492-6468
Practice Address - Street 1:103A CLUBHOUSE LN
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-8108
Practice Address - Country:US
Practice Address - Phone:513-313-8906
Practice Address - Fax:513-492-6468
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2900301172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2900301Medicaid