1225325400 NPI number — MS. SUSAN Y SERVIN LCSW

Table of content: MS. SUSAN Y SERVIN LCSW (NPI 1225325400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225325400 NPI number — MS. SUSAN Y SERVIN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SERVIN
Provider First Name:
SUSAN
Provider Middle Name:
Y
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

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 Information

NPI Number:
1225325400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111B CHASTA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STRATFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06614-8165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-980-7560
Provider Business Mailing Address Fax Number:
203-795-8905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111B CHASTA LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STRATFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06614-8165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-980-7560
Provider Business Practice Location Address Fax Number:
203-795-8905
Provider Enumeration Date:
07/07/2011

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:  003557 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12255687 . This is a "CAQH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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