Provider Demographics
NPI:1003196809
Name:MALEWICZ, SUSAN (LCSW CASAC CSAT SAP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MALEWICZ
Suffix:
Gender:F
Credentials:LCSW CASAC CSAT SAP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MALEWICZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW CASAC CSAT SAP
Mailing Address - Street 1:600 JOHNSON AVE
Mailing Address - Street 2:SUITE B7
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2614
Mailing Address - Country:US
Mailing Address - Phone:631-750-5616
Mailing Address - Fax:631-750-5616
Practice Address - Street 1:600 JOHNSON AVE
Practice Address - Street 2:SUITE B7
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2614
Practice Address - Country:US
Practice Address - Phone:631-750-5616
Practice Address - Fax:631-750-5616
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0769091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY27-1977121OtherEIN