Provider Demographics
NPI:1194769364
Name:PEREL, SUSAN DARA
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:DARA
Last Name:PEREL
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 1:788 TODT HILL RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1327
Mailing Address - Country:US
Mailing Address - Phone:718-667-3800
Mailing Address - Fax:718-980-9281
Practice Address - Street 1:27 NEW DORP LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2322
Practice Address - Country:US
Practice Address - Phone:718-667-3597
Practice Address - Fax:718-667-3590
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0348451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN534D1Medicare ID - Type Unspecified