Healthcare Provider Details

I. General information

NPI: 1720172935
Provider Name (Legal Business Name): SUSAN BREITHAUPT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 LARGE AVENUE
HILLSDALE NJ
07642
US

IV. Provider business mailing address

98 LARGE AVE
HILLSDALE NJ
07642
US

V. Phone/Fax

Practice location:
  • Phone: 201-664-8916
  • Fax: 201-664-1378
Mailing address:
  • Phone: 201-664-8916
  • Fax: 201-664-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC04596200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: