=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447332440
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA SUSSEL MSS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 MONUMENT ROAD BELMONT CENTER
-----------------------------------------------------
City | PHILAELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-581-9142
-----------------------------------------------------
Fax | 215-581-3827
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2947 MAPLESHADE RD
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19003-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-581-9142
-----------------------------------------------------
Fax | 215-581-3827
-----------------------------------------------------
=====================================================
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 | CW014864
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------