Provider Demographics
NPI:1669097424
Name:JENCZKA, SUSAN BRAY (LCPC, LCAT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:BRAY
Last Name:JENCZKA
Suffix:
Gender:F
Credentials:LCPC, LCAT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:BRAY
Other - Last Name:WESLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC, LCAT
Mailing Address - Street 1:6 MAPLEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1531
Mailing Address - Country:US
Mailing Address - Phone:716-270-3172
Mailing Address - Fax:
Practice Address - Street 1:6 MAPLEVIEW RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-1531
Practice Address - Country:US
Practice Address - Phone:716-270-3172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1874101YM0800X
NY001851-1225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist