Provider Demographics
NPI:1912945015
Name:VAN LEAVEN, SUSAN (LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:VAN LEAVEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 OAKLAWN AVE
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-2649
Mailing Address - Country:US
Mailing Address - Phone:401-228-7914
Mailing Address - Fax:
Practice Address - Street 1:1255 OAKLAWN AVE
Practice Address - Street 2:SUITE # 2
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-2649
Practice Address - Country:US
Practice Address - Phone:401-228-7914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW005221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI406424OtherBLUE CHIP
RI30885-4OtherBLUE CROSS
RISG12457Medicaid
RI62-15766OtherUNITED BEHAVIORAL HEALTH
RISG12457Medicaid