Provider Demographics
NPI:1982233011
Name:DUBOURG, SUSAN A (LMSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:DUBOURG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 OAKLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1621
Mailing Address - Country:US
Mailing Address - Phone:516-674-9158
Mailing Address - Fax:
Practice Address - Street 1:43 OAKLAWN AVE # 1A
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-1621
Practice Address - Country:US
Practice Address - Phone:917-846-3861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103167-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker