Provider Demographics
NPI:1215080155
Name:WILLINGHAM, SUSANNA KITSON (MPS,ATR-BC, NCPSYA)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:KITSON
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:MPS,ATR-BC, NCPSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 PIERMONT AVE.
Mailing Address - Street 2:2D
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-3861
Mailing Address - Country:US
Mailing Address - Phone:845-358-0722
Mailing Address - Fax:
Practice Address - Street 1:50 PIERMONT AVE
Practice Address - Street 2:2D
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-3841
Practice Address - Country:US
Practice Address - Phone:845-358-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLMHC2939101YM0800X
NYLPSYA412101YM0800X
NYLCAT702101YM0800X
NYLPC234300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health