Provider Demographics
NPI:1336328491
Name:SUSSAL, MICHAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SUSSAL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 HITCHCOCK RD
Mailing Address - Street 2:#162
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-3965
Mailing Address - Country:US
Mailing Address - Phone:203-591-8825
Mailing Address - Fax:
Practice Address - Street 1:270 FARMINGTON AVE
Practice Address - Street 2:SUITE 309
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1909
Practice Address - Country:US
Practice Address - Phone:860-677-5570
Practice Address - Fax:860-677-9570
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0061221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical