Provider Demographics
NPI:1639940497
Name:SPORN, SUSAN R (LAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:SPORN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:R
Other - Last Name:TEPPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:9 MIMOSA CT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-1239
Mailing Address - Country:US
Mailing Address - Phone:917-596-3050
Mailing Address - Fax:
Practice Address - Street 1:139 OCEAN AVE STE 1B
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-3668
Practice Address - Country:US
Practice Address - Phone:848-245-5359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00599000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health