Healthcare Provider Details

I. General information

NPI: 1720208622
Provider Name (Legal Business Name): SUSAN DENISE BANCROFT LPCC-S, LICDC, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4970 BELMONT AVE
YOUNGSTOWN OH
44505-1018
US

IV. Provider business mailing address

150 E MARKET ST
WARREN OH
44481-1141
US

V. Phone/Fax

Practice location:
  • Phone: 330-759-8237
  • Fax:
Mailing address:
  • Phone: 330-399-6451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number981149
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS 0014236
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.0002756-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: