1841293990 NPI number — SUSAN WORTSMAN MA-CCC

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	WORTSMAN
Provider First Name	:	SUSAN
Provider Middle Name	:
Provider Name Prefix Text	:
Provider Name Suffix Text	:
Provider Credential Text	:	MA-CCC
Provider Gender Code	:	F

Provider Other Organization Name	:
Provider Other Organization Name Type Code	:
Provider Other Last Name	:
Provider Other First Name	:
Provider Other Middle Name	:
Provider Other Name Prefix Text	:
Provider Other Name Suffix Text	:
Provider Other Credential Text	:
Provider Other Last Name Type Code	:

NPI Number	:	1841293990
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/08/2007
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
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Provider First Line Business Mailing Address	:	68 ROCKLEDGE RD
Provider Second Line Business Mailing Address	:	APT 1C
Provider Business Mailing Address City Name	:	HARTSDALE
Provider Business Mailing Address State Name	:	NY
Provider Business Mailing Address Postal Code	:	105303455
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	2124814464
Provider Business Mailing Address Fax Number	:

Provider First Line Business Practice Location Address	:	425 E 25TH ST
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	NEW YORK
Provider Business Practice Location Address State Name	:	NY
Provider Business Practice Location Address Postal Code	:	100102547
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	2124814464
Provider Business Practice Location Address Fax Number	:
Provider Enumeration Date	:	05/23/2005

Authorized Official Last Name	:
Authorized Official First Name	:
Authorized Official Middle Name	:
Authorized Official Title or Position	:
Authorized Official Telephone Number	:

• Taxonomy code: 231H00000X , with the licence number:  000396-1 , registered in the state of NY .

• Identifier: M72081 . This is a "PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "".