Provider Demographics
NPI:1700901568
Name:BANDLER WAGNER, SUSAN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:BANDLER WAGNER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:BANDLER WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:NEWFANE
Mailing Address - State:VT
Mailing Address - Zip Code:05345-0344
Mailing Address - Country:US
Mailing Address - Phone:802-365-9115
Mailing Address - Fax:
Practice Address - Street 1:23 WEST STREET
Practice Address - Street 2:
Practice Address - City:NEWFANE
Practice Address - State:VT
Practice Address - Zip Code:05345
Practice Address - Country:US
Practice Address - Phone:802-365-9115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00003301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical