MEDICARE: SUSAN M DORNAN BS, CASAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	18618	NY

General Provider Information

NPI Number	:	1639291156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M DORNAN BS, CASAC

Provider Business Mailing Address
First Line	:	100 PARK ST
Second Line	:
City	:	GLENS FALLS
State	:	NY
Zip	:	12801-4413
Country	:	US
Telephone Number	:	518-926-3207
Fax Number	:	518-926-3215

Provider Business Practice Location Address
First Line	:	340 MAIN ST
Second Line	:
City	:	HUDSON FALLS
State	:	NY
Zip	:	12839-1530
Country	:	US
Telephone Number	:	518-747-8001
Fax Number	:	518-747-8003

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/08/2007

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