MEDICARE: MS. SUZANNE VIZETHANN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	080479	NY

General Provider Information

NPI Number	:	1215231410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUZANNE VIZETHANN LCSW

Provider Business Mailing Address
First Line	:	102 BEACH ST
Second Line	:
City	:	CORNWALL
State	:	NY
Zip	:	12518-1725
Country	:	US
Telephone Number	:	845-534-3704
Fax Number	:

Provider Business Practice Location Address
First Line	:	3250 ROUTE 9W
Second Line	:
City	:	NEW WINDSOR
State	:	NY
Zip	:	12553-6756
Country	:	US
Telephone Number	:	845-562-9816
Fax Number	:	845-863-0351

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2011
Last Update Date	:	10/26/2015

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