Provider Demographics
NPI:1013091719
Name:SUSANIN, DAVID (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:SUSANIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 BRIMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-3206
Mailing Address - Country:US
Mailing Address - Phone:860-529-9113
Mailing Address - Fax:
Practice Address - Street 1:500 VINE ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1639
Practice Address - Country:US
Practice Address - Phone:860-297-0810
Practice Address - Fax:860-293-6356
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0049011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical