Provider Demographics
NPI:1902993272
Name:SUFFOLK COUNTY DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:SUFFOLK COUNTY DEPARTMENT OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURBIIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-854-2571
Mailing Address - Street 1:95 TULIPWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 HORSEBLOCK PL
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1204
Practice Address - Country:US
Practice Address - Phone:631-543-3659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0497521251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354807Medicaid
NYW02771Medicare ID - Type Unspecified