Provider Demographics
NPI:1992021604
Name:VELAZQUEZ, SUZANNE L (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:L
Last Name:VELAZQUEZ
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1246
Mailing Address - Country:US
Mailing Address - Phone:631-698-1736
Mailing Address - Fax:
Practice Address - Street 1:83 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8305
Practice Address - Country:US
Practice Address - Phone:631-666-5067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0834151041C0700X
NY077805104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker