Provider Demographics
NPI:1760593925
Name:VITEK, SUSAN P (LCSWR)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:VITEK
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 NEW YORK AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-4240
Mailing Address - Country:US
Mailing Address - Phone:631-271-2999
Mailing Address - Fax:631-424-4041
Practice Address - Street 1:755 NEW YORK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4240
Practice Address - Country:US
Practice Address - Phone:631-271-2999
Practice Address - Fax:631-424-4041
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0585581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02383902Medicaid
NYN3G011Medicare ID - Type Unspecified
NY02383902Medicaid