1003196809 NPI number — SUSAN MALEWICZ LCSW CASAC CSAT SAP

Table of content: SUSAN MALEWICZ LCSW CASAC CSAT SAP (NPI 1003196809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003196809 NPI number — SUSAN MALEWICZ LCSW CASAC CSAT SAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALEWICZ
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW CASAC CSAT SAP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MALEWICZ
Provider Other First Name:
SUSAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW CASAC CSAT SAP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1003196809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 JOHNSON AVE
Provider Second Line Business Mailing Address:
SUITE B7
Provider Business Mailing Address City Name:
BOHEMIA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11716-2614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-750-5616
Provider Business Mailing Address Fax Number:
631-750-5616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 JOHNSON AVE
Provider Second Line Business Practice Location Address:
SUITE B7
Provider Business Practice Location Address City Name:
BOHEMIA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11716-2614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-750-5616
Provider Business Practice Location Address Fax Number:
631-750-5616
Provider Enumeration Date:
08/24/2011

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  076909 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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