Provider Demographics
NPI:1235697285
Name:PICCONE, SUSAN MATLIN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MATLIN
Last Name:PICCONE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W CENTER ST STE C3
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4870
Mailing Address - Country:US
Mailing Address - Phone:844-428-8728
Mailing Address - Fax:860-432-1477
Practice Address - Street 1:200 W CENTER ST STE C3
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4870
Practice Address - Country:US
Practice Address - Phone:844-428-8728
Practice Address - Fax:860-432-1477
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3637101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional