=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114008836
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN E RAMBO LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 10/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 308 MAIN ST STIRLING SQUARE
-----------------------------------------------------
City | GREENPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11944-1418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-345-2876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 FRONT ST APT. B
-----------------------------------------------------
City | GREENPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11944-1654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-345-2876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0890001005
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------