Healthcare Provider Details

I. General information

NPI: 1265431936
Provider Name (Legal Business Name): SUSANNE GROENENDAAL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S BURROWES ST
STATE COLLEGE PA
16801-3894
US

IV. Provider business mailing address

119 S BURROWES ST
STATE COLLEGE PA
16801-3894
US

V. Phone/Fax

Practice location:
  • Phone: 814-441-7456
  • Fax: 814-238-1875
Mailing address:
  • Phone: 814-441-7456
  • Fax: 814-238-1875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW-000305-L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier007032703
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier010988
Identifier TypeOTHER
Identifier State
Identifier IssuerTRICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: