Healthcare Provider Details

I. General information

NPI: 1902857576
Provider Name (Legal Business Name): SUSAN KRUK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2061 FAIRVIEW AVE 2ND. FLOOR
EASTON PA
18042-3953
US

IV. Provider business mailing address

2061 FAIRVIEW AVE 2ND FLOOR
EASTON PA
18042-3953
US

V. Phone/Fax

Practice location:
  • Phone: 610-923-0411
  • Fax: 610-923-5188
Mailing address:
  • Phone: 610-923-0411
  • Fax: 610-923-5188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW007328L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: