Provider Demographics
NPI:1598098121
Name:WEBSTER VAN DRIE, SUSAN H (LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:WEBSTER VAN DRIE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 STINSON RD
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-5012
Mailing Address - Country:US
Mailing Address - Phone:978-470-0107
Mailing Address - Fax:
Practice Address - Street 1:99 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2621
Practice Address - Country:US
Practice Address - Phone:978-458-6282
Practice Address - Fax:978-441-9826
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1108081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1305638Medicaid