Provider Demographics
NPI:1114065364
Name:GIANNICO, SUSAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GIANNICO
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 1:255 BULL RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10992
Mailing Address - Country:US
Mailing Address - Phone:845-496-4919
Mailing Address - Fax:
Practice Address - Street 1:61 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTONVILLE
Practice Address - State:NY
Practice Address - Zip Code:10992
Practice Address - Country:US
Practice Address - Phone:845-496-4919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR02809911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02261118Medicaid
NY7927388OtherAETNA
NY133120OtherVALUE OPTIONS