Provider Demographics
NPI:1336254572
Name:OTTENHEIMER, SUSAN (LCSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:OTTENHEIMER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:OTTENHEIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:47 TRUMBULL ST STE 101
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-1016
Mailing Address - Country:US
Mailing Address - Phone:203-776-7996
Mailing Address - Fax:
Practice Address - Street 1:47 TRUMBULL ST STE 101
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-1016
Practice Address - Country:US
Practice Address - Phone:203-776-7996
Practice Address - Fax:203-453-9065
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0008091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000809OtherLICENSE (LCSW)
304468OtherMHN HMC
140000809CT01OtherANTHEM