Provider Demographics
NPI:1619181336
Name:SMITH, SUSAN DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:SMITH
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 1:165 SEAMAN AVE
Mailing Address - Street 2:6J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-1910
Mailing Address - Country:US
Mailing Address - Phone:917-748-9054
Mailing Address - Fax:212-567-6513
Practice Address - Street 1:165 SEAMAN AVE
Practice Address - Street 2:6J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1910
Practice Address - Country:US
Practice Address - Phone:917-748-9054
Practice Address - Fax:212-567-6513
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR041492-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical