Provider Demographics
NPI:1104927862
Name:DEWITT-GLICKMAN, SUSAN A (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:A
Last Name:DEWITT-GLICKMAN
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 1:3 FAMILY PRACTICE DRIVE
Mailing Address - Street 2:FAMILY PRACTICE CENTER
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401
Mailing Address - Country:US
Mailing Address - Phone:845-338-2562
Mailing Address - Fax:845-338-8909
Practice Address - Street 1:3 FAMILY PRACTICE DRIVE
Practice Address - Street 2:FAMILY PRACTICE CENTER
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401
Practice Address - Country:US
Practice Address - Phone:845-338-2562
Practice Address - Fax:845-338-8909
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR039985-11041C0700X
NYPR03998512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00733871Medicaid
NYN5G931Medicare ID - Type Unspecified
S24480Medicare UPIN