Provider Demographics
NPI:1730278342
Name:PERREAULT, SUZANNE MARIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:MARIE
Last Name:PERREAULT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:MARIE
Other - Last Name:CIDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW
Mailing Address - Street 1:138 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-2059
Mailing Address - Country:US
Mailing Address - Phone:607-351-1795
Mailing Address - Fax:
Practice Address - Street 1:138 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-2059
Practice Address - Country:US
Practice Address - Phone:607-351-1795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071401-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02876548Medicaid
NYIA1224Medicare PIN
NY02876548Medicaid