MEDICARE: SUSAN M LEGERE 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	072481-1	NY

General Provider Information

NPI Number	:	1235416124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M LEGERE LCSW

Provider Business Mailing Address
First Line	:	48 NEW JERSEY AVE
Second Line	:
City	:	RENSSELAER
State	:	NY
Zip	:	12144-3307
Country	:	US
Telephone Number	:	518-433-9505
Fax Number	:

Provider Business Practice Location Address
First Line	:	48 NEW JERSEY AVE
Second Line	:
City	:	RENSSELAER
State	:	NY
Zip	:	12144-3307
Country	:	US
Telephone Number	:	518-433-9505
Fax Number	:

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

Provider Enumeration Date	:	11/07/2011
Last Update Date	:	11/07/2011

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