Healthcare Provider Details

I. General information

NPI: 1225028616
Provider Name (Legal Business Name): SUSAN M COHEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 BAXTER RD
STORRS CT
06268-1109
US

IV. Provider business mailing address

45 BAXTER RD
STORRS CT
06268-1109
US

V. Phone/Fax

Practice location:
  • Phone: 860-429-0326
  • Fax: 860-429-9623
Mailing address:
  • Phone: 860-429-0326
  • Fax: 860-429-9623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number003966
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: