Basic Information
| Provider Information | |||||||||
| NPI: | 1316322324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AICH | ||||||||
| FirstName: | SUSANNA | ||||||||
| MiddleName: | LORRAINE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 59 SOUTHLAND CT | ||||||||
| Address2: | |||||||||
| City: | MAUMELLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721136262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013912793 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 915 OAK ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720324389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017251163 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2015 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 8424-C | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.