Provider Demographics
NPI:1760950778
Name:GAYNOR, SUSAN E
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:GAYNOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11690 NEELSVILLE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-4127
Mailing Address - Country:US
Mailing Address - Phone:301-353-0972
Mailing Address - Fax:
Practice Address - Street 1:11690 NEELSVILLE CHURCH RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4127
Practice Address - Country:US
Practice Address - Phone:301-353-0972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD060481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty