Provider Demographics
NPI:1063801967
Name:LEE, SUSANNE
Entity type:Individual
Prefix:MS
First Name:SUSANNE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4978
Mailing Address - Country:US
Mailing Address - Phone:120-320-0210
Mailing Address - Fax:203-688-2395
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:120-320-0212
Practice Address - Fax:203-688-2395
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT60941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical