Provider Demographics
NPI:1700112174
Name:ERICSON, SUSAN M (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:ERICSON
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 1:64 ROBBINS ST
Mailing Address - Street 2:WATERBURY HOSPITAL - CRISIS CENTER
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06721
Mailing Address - Country:US
Mailing Address - Phone:203-573-6103
Mailing Address - Fax:203-573-7240
Practice Address - Street 1:64 ROBBINS ST
Practice Address - Street 2:WATERBURY HOSPITAL - CRISIS CENTER
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06721
Practice Address - Country:US
Practice Address - Phone:203-573-6103
Practice Address - Fax:203-573-7240
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0071071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical