=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609015445
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD LEWIS SUSSMAN MSW, LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2009
-----------------------------------------------------
Last Update Date | 02/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 SASQUA TRL
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06883-1025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-544-8418
-----------------------------------------------------
Fax | 203-544-7168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 SASQUA TRL
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06883-1025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-544-8418
-----------------------------------------------------
Fax | 203-544-7168
-----------------------------------------------------
=====================================================
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 | R0173571
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------