Provider Demographics
NPI:1508079443
Name:GARDNER, SUSAN ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELLEN
Last Name:GARDNER
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 1:4250 SUNRISE HWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5338
Mailing Address - Country:US
Mailing Address - Phone:516-799-4864
Mailing Address - Fax:516-797-7210
Practice Address - Street 1:4250 SUNRISE HWY
Practice Address - Street 2:SUITE 103
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5338
Practice Address - Country:US
Practice Address - Phone:516-799-4864
Practice Address - Fax:516-797-7210
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR018985-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN77301Medicare ID - Type UnspecifiedCLINICAL SOCIAL WORKER