Provider Demographics
NPI:1144431511
Name:GYDESEN, SUSAN ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:GYDESEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6944 WILLIAM ST.
Mailing Address - Street 2:PO BOX 472
Mailing Address - City:CROGHAN
Mailing Address - State:NY
Mailing Address - Zip Code:13327
Mailing Address - Country:US
Mailing Address - Phone:315-346-1541
Mailing Address - Fax:
Practice Address - Street 1:120 SCHUYLER ST
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:NY
Practice Address - Zip Code:13309-1005
Practice Address - Country:US
Practice Address - Phone:315-942-4252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR039553-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical