Provider Demographics
NPI:1235291006
Name:EGELKO, SUSAN ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:EGELKO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 GRAMERCY PARK N
Mailing Address - Street 2:#6C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-6302
Mailing Address - Country:US
Mailing Address - Phone:212-387-0254
Mailing Address - Fax:
Practice Address - Street 1:137 E 36TH ST
Practice Address - Street 2:SUITE #1L
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3528
Practice Address - Country:US
Practice Address - Phone:347-612-6861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7742-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV162I1Medicare ID - Type UnspecifiedPSYCHOLOGIST