Provider Demographics
NPI:1275005860
Name:SUSSEK, DONNA M (LICSW)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:SUSSEK
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 1:2036 ROARING BROOK RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:MA
Mailing Address - Zip Code:01341-9649
Mailing Address - Country:US
Mailing Address - Phone:413-522-2044
Mailing Address - Fax:
Practice Address - Street 1:319 BEECH ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-3968
Practice Address - Country:US
Practice Address - Phone:413-540-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10271431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1027143Medicaid