Provider Demographics
NPI:1346634136
Name:GOLDFARB, SUSAN (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GOLDFARB
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 MAIN ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-1139
Mailing Address - Country:US
Mailing Address - Phone:203-220-2208
Mailing Address - Fax:203-220-2247
Practice Address - Street 1:477 MAIN ST
Practice Address - Street 2:SUITE 208
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-1139
Practice Address - Country:US
Practice Address - Phone:203-220-2208
Practice Address - Fax:203-220-2247
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000418101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004227402Medicaid