Provider Demographics
NPI:1174190276
Name:RICE, SUSAN MARION (LAC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARION
Last Name:RICE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 VAN GOGH LN
Mailing Address - Street 2:
Mailing Address - City:AIRMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10901-7717
Mailing Address - Country:US
Mailing Address - Phone:845-553-5530
Mailing Address - Fax:
Practice Address - Street 1:545 ISLAND RD STE 2B
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-2822
Practice Address - Country:US
Practice Address - Phone:201-995-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00505100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health