Provider Demographics
NPI:1043366792
Name:GAVIN, SUZANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:GAVIN
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 1:1 BARSTOW RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3540
Mailing Address - Country:US
Mailing Address - Phone:516-236-3116
Mailing Address - Fax:
Practice Address - Street 1:1 BARSTOW RD
Practice Address - Street 2:SUITE P24
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3540
Practice Address - Country:US
Practice Address - Phone:516-236-3116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00073797104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00073797Medicaid
NY00073797Medicaid