Provider Demographics
NPI:1528171154
Name:VEDRAL, SUSAN MARIE (LCSW-C)
Entity type:Individual
Prefix:PROF
First Name:SUSAN
Middle Name:MARIE
Last Name:VEDRAL
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:PROF
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:FABIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8106 EDWILL AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-1618
Mailing Address - Country:US
Mailing Address - Phone:410-825-2281
Mailing Address - Fax:410-825-0757
Practice Address - Street 1:1407 YORK RD
Practice Address - Street 2:SUITE309
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6097
Practice Address - Country:US
Practice Address - Phone:410-825-2281
Practice Address - Fax:410-825-0757
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD105951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT080-0024OtherBLUECHOICE MEMBER NUMBER
MDT080-0024OtherBLUECHOICE MEMBER NUMBER