MEDICARE: MS. SUSAN BLUESTONE KOPLOVITZ SUSAN BLUESTONE,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	R026530	NY

General Provider Information

NPI Number	:	1326102880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN BLUESTONE KOPLOVITZ SUSAN BLUESTONE,LCSW

Provider Business Mailing Address
First Line	:	345 E 72ND ST
Second Line	:	3C
City	:	NEW YORK
State	:	NY
Zip	:	10021-4623
Country	:	US
Telephone Number	:	212-628-1759
Fax Number	:	212-628-1759

Provider Business Practice Location Address
First Line	:	345 E 72ND ST
Second Line	:	3C
City	:	NEW YORK
State	:	NY
Zip	:	10021-4623
Country	:	US
Telephone Number	:	212-628-1759
Fax Number	:	212-628-1759

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

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	07/08/2007

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