=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376032789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSAN SUTTON FRAGER LCSW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2018
-----------------------------------------------------
Last Update Date | 05/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BALA AVE
-----------------------------------------------------
City | BALA CYNWYD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19004-3212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-247-7246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 BALA AVE
-----------------------------------------------------
City | BALA CYNWYD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19004-3212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-247-7246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCSW
-----------------------------------------------------
Name | SUSAN SUTTON FRAGER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 610-247-7246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | CW017234
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------