Provider Demographics
NPI:1225054976
Name:MEDYN, SUSAN M (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:MEDYN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 NORTH CT
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-4724
Mailing Address - Country:US
Mailing Address - Phone:401-816-0554
Mailing Address - Fax:506-636-0601
Practice Address - Street 1:866 MAIN RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:MA
Practice Address - Zip Code:02790-4311
Practice Address - Country:US
Practice Address - Phone:781-789-1236
Practice Address - Fax:508-636-0601
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10183491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP05297OtherBC
MAP05297OtherBC