Provider Demographics
NPI:1548314941
Name:BAGNINI, SUSAN M (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:BAGNINI
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 1:100 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-1842
Mailing Address - Country:US
Mailing Address - Phone:516-944-8457
Mailing Address - Fax:516-883-3473
Practice Address - Street 1:100 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-1842
Practice Address - Country:US
Practice Address - Phone:516-944-8457
Practice Address - Fax:516-883-3473
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLCSW#PR0149491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY50089OtherGHI
NY072575OtherVALUE OPTIONS
NYN26901Medicare ID - Type Unspecified