Provider Demographics
NPI:1568860864
Name:PESTANA-SZWARC, SUSANA (MS)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:PESTANA-SZWARC
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 EASTBOURNE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-5501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1717
Practice Address - Country:US
Practice Address - Phone:732-747-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ21-0634494Medicaid