Provider Demographics
NPI:1811739691
Name:THOMAS, SUSAN (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:EBENAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:28 TRACY LN
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-3413
Mailing Address - Country:US
Mailing Address - Phone:631-793-9123
Mailing Address - Fax:
Practice Address - Street 1:28 TRACY LN
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-3413
Practice Address - Country:US
Practice Address - Phone:631-793-9123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY15185-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical