Provider Demographics
NPI:1447568001
Name:ROELLER, SUSAN LYNNE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNNE
Last Name:ROELLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BRENNER AVE
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-4301
Mailing Address - Country:US
Mailing Address - Phone:516-932-4395
Mailing Address - Fax:
Practice Address - Street 1:350 MARTHA AVE
Practice Address - Street 2:
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713-1525
Practice Address - Country:US
Practice Address - Phone:631-286-6925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO366351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical