Provider Demographics
NPI:1114008836
Name:RAMBO, SUSAN E (LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:RAMBO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:G
Other - Last Name:ELLOR-CASE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:124 FRONT ST
Mailing Address - Street 2:APT. B
Mailing Address - City:GREENPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11944-1654
Mailing Address - Country:US
Mailing Address - Phone:802-345-2876
Mailing Address - Fax:
Practice Address - Street 1:308 MAIN ST
Practice Address - Street 2:STIRLING SQUARE
Practice Address - City:GREENPORT
Practice Address - State:NY
Practice Address - Zip Code:11944-1418
Practice Address - Country:US
Practice Address - Phone:802-345-2876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900010051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00059888OtherBCBS
VT1010391Medicaid
VTVN3331Medicare ID - Type Unspecified