Provider Demographics
NPI:1730652264
Name:PITAK DAVIS, SUSANNE (LPC 01178)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:PITAK DAVIS
Suffix:
Gender:F
Credentials:LPC 01178
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08530-2304
Mailing Address - Country:US
Mailing Address - Phone:609-947-3057
Mailing Address - Fax:
Practice Address - Street 1:8 GRANT AVE
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08530-2304
Practice Address - Country:US
Practice Address - Phone:609-947-3057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC001178000101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ01178OtherBEHAVIORAL BOARD OF EXAMINERS