Provider Demographics
NPI:1265431936
Name:GROENENDAAL, SUSANNE (LCSW)
Entity type:Individual
Prefix:MS
First Name:SUSANNE
Middle Name:
Last Name:GROENENDAAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S BURROWES ST
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-3894
Mailing Address - Country:US
Mailing Address - Phone:814-441-7456
Mailing Address - Fax:814-238-1875
Practice Address - Street 1:119 S BURROWES ST
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-3894
Practice Address - Country:US
Practice Address - Phone:814-441-7456
Practice Address - Fax:814-238-1875
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW-000305-L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA007032703Medicaid
010988OtherTRICARE