Provider Demographics
NPI:1689683534
Name:MEDOFF, SUSAN M (MSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:MEDOFF
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ALLENS CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-3305
Mailing Address - Country:US
Mailing Address - Phone:585-461-0065
Mailing Address - Fax:585-271-1129
Practice Address - Street 1:130 ALLENS CREEK ROAD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-3305
Practice Address - Country:US
Practice Address - Phone:585-461-0065
Practice Address - Fax:585-271-1129
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104032104100000X
NYRO286391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7692315OtherAETNA
NY100382FKOtherPREFERRED CARE
NYPO10028639OtherBCBS
NY12005BMedicare ID - Type Unspecified