Provider Demographics
NPI:1225325400
Name:SERVIN, SUSAN Y (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:Y
Last Name:SERVIN
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 1:111B CHASTA LN
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-8165
Mailing Address - Country:US
Mailing Address - Phone:203-980-7560
Mailing Address - Fax:203-795-8905
Practice Address - Street 1:111B CHASTA LN
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-8165
Practice Address - Country:US
Practice Address - Phone:203-980-7560
Practice Address - Fax:203-795-8905
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0035571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12255687OtherCAQH