Provider Demographics
NPI:1093833915
Name:BRENNER, SUSAN LEE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LEE
Last Name:BRENNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:LEE
Other - Last Name:LASKOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:73 JUNE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3014
Mailing Address - Country:US
Mailing Address - Phone:631-651-8900
Mailing Address - Fax:
Practice Address - Street 1:73 JUNE AVE
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3014
Practice Address - Country:US
Practice Address - Phone:631-651-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0241111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN6J341Medicare ID - Type Unspecified