Provider Demographics
NPI:1700958212
Name:BOURBIN, SUSAN JOAN (LACSW-R)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JOAN
Last Name:BOURBIN
Suffix:
Gender:F
Credentials:LACSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 TULIPWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5625
Mailing Address - Country:US
Mailing Address - Phone:631-854-2552
Mailing Address - Fax:631-854-2550
Practice Address - Street 1:15 HORSEBLOCK PLACE
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738
Practice Address - Country:US
Practice Address - Phone:631-854-2552
Practice Address - Fax:631-854-2550
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO49752-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRO49752-1OtherSW LICENSE #
NYRO49752-1OtherSW LICENSE #