Provider Demographics
NPI:1871503698
Name:BLOOMFIELD, SUSAN G (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:G
Last Name:BLOOMFIELD
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579-1915
Mailing Address - Country:US
Mailing Address - Phone:516-671-8704
Mailing Address - Fax:
Practice Address - Street 1:6729 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7063
Practice Address - Country:US
Practice Address - Phone:718-456-7001
Practice Address - Fax:718-456-9470
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0245781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244624Medicaid
NY00244624Medicaid