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General NPI Number Information
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NPI Number | 1205088473
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Entity Type | Individual
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Provider Name | JENNIE SUCILSKY LCSW
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Gender | Female
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Dates
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Enumeration Date | 10/18/2008
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Last Update Date | 11/10/2021
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Provider Practice Location Address
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Address Line | 11 TERRI DR
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City | KINGS PARK
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State | NY
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Zip | 11754-5029
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Country | US
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Telephone | 631-816-6138
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Fax |
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Provider Business Mailing Address
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Address Line | 11 FARBER DR STE D
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City | BELLPORT
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State | NY
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Zip | 11713-1500
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 081747
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License Number State | NY
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