Provider Demographics
NPI:1992862973
Name:NUSSBAUM, SUSAN ELLEN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELLEN
Last Name:NUSSBAUM
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 1:1 RIVER PL APT 1019
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-4367
Mailing Address - Country:US
Mailing Address - Phone:516-860-4096
Mailing Address - Fax:516-626-2383
Practice Address - Street 1:1 RIVER PL APT 1019
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-4367
Practice Address - Country:US
Practice Address - Phone:516-860-4096
Practice Address - Fax:631-561-6201
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041837-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker