Provider Demographics
NPI:1669588968
Name:DONNELLY, SUSAN JOAN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:JOAN
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:JOAN
Other - Last Name:DONNELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:115 PINE ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-1619
Mailing Address - Country:US
Mailing Address - Phone:201-447-0364
Mailing Address - Fax:201-445-2354
Practice Address - Street 1:115 PINE STREET
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-447-0364
Practice Address - Fax:201-445-2354
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC00206800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SWL4705997OtherMALPRACTICE INSURANCE
NJ44SC00206800OtherLCSW LICENSE
SWL4705997OtherMALPRACTICE INSURANCE