Provider Demographics
NPI:1063559185
Name:KORN, SUSAN (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KORN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 PARK ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2935
Mailing Address - Country:US
Mailing Address - Phone:973-746-1065
Mailing Address - Fax:973-744-1188
Practice Address - Street 1:103 PARK ST STE 2A
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2935
Practice Address - Country:US
Practice Address - Phone:973-746-1065
Practice Address - Fax:973-744-1188
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSC086421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP672728OtherOXFORD ID
NJ223357620OtherEIN #
NJP672728OtherOXFORD ID