Provider Demographics
NPI:1174858625
Name:PELOSI, SUSAN MANLY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MANLY
Last Name:PELOSI
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 1:48 OLD POST RD N
Mailing Address - Street 2:
Mailing Address - City:RED HOOK
Mailing Address - State:NY
Mailing Address - Zip Code:12571-2220
Mailing Address - Country:US
Mailing Address - Phone:845-758-4499
Mailing Address - Fax:
Practice Address - Street 1:59 W MARKET ST
Practice Address - Street 2:
Practice Address - City:RED HOOK
Practice Address - State:NY
Practice Address - Zip Code:12571-1534
Practice Address - Country:US
Practice Address - Phone:646-236-3077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR048011-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical