Healthcare Provider Details

I. General information

NPI: 1144431511
Provider Name (Legal Business Name): SUSAN ELIZABETH GYDESEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SCHUYLER ST
BOONVILLE NY
13309-1005
US

IV. Provider business mailing address

6944 WILLIAM ST. PO BOX 472
CROGHAN NY
13327
US

V. Phone/Fax

Practice location:
  • Phone: 315-942-4252
  • Fax:
Mailing address:
  • Phone: 315-346-1541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR039553-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: