Provider Demographics
NPI:1639234396
Name:LOBACZ, SUSAN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:J
Last Name:LOBACZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-0608
Mailing Address - Country:US
Mailing Address - Phone:631-859-0228
Mailing Address - Fax:631-224-4156
Practice Address - Street 1:100 S MAIN ST
Practice Address - Street 2:SUITE 206
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-3100
Practice Address - Country:US
Practice Address - Phone:631-859-0228
Practice Address - Fax:631-224-4156
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011556103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVOH943Medicare ID - Type Unspecified