MEDICARE: SUSAN JANE MORDUCH PHD

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	103T00000X	Psychologist	014634-1	NY
2	103TC0700X	Clinical Psychologist	014634	NY

General Provider Information

NPI Number	:	1417253485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN JANE MORDUCH PHD

Provider Business Mailing Address
First Line	:	547 SAW MILL RIVER RD
Second Line	:	STE 1D
City	:	ARDSLEY
State	:	NY
Zip	:	10502-2154
Country	:	US
Telephone Number	:	212-851-8102
Fax Number	:	212-537-0102

Provider Business Practice Location Address
First Line	:	547 SAW MILL RIVER RD
Second Line	:	STE 1D
City	:	ARDSLEY
State	:	NY
Zip	:	10502-2154
Country	:	US
Telephone Number	:	212-851-8102
Fax Number	:	212-537-0102

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

Provider Enumeration Date	:	02/08/2011
Last Update Date	:	02/25/2020

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