Provider Demographics
NPI:1013014687
Name:DRYSDALE, SUSAN MAXINE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MAXINE
Last Name:DRYSDALE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 HENNESSEY DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3826
Mailing Address - Country:US
Mailing Address - Phone:631-673-2940
Mailing Address - Fax:631-673-2940
Practice Address - Street 1:63 HENNESSEY DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3826
Practice Address - Country:US
Practice Address - Phone:631-673-2940
Practice Address - Fax:631-673-2940
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-041651-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR-041651-1OtherREGISTERED SOCIAL WORKER
NYR-041651-1OtherREGISTERED SOCIAL WORKER