Provider Demographics
NPI:1427687045
Name:DAVIDSON, SUSAN LYNN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:DAVIDSON
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:PO BOX 647
Mailing Address - Street 2:
Mailing Address - City:FORT MONTGOMERY
Mailing Address - State:NY
Mailing Address - Zip Code:10922-0647
Mailing Address - Country:US
Mailing Address - Phone:845-656-5461
Mailing Address - Fax:
Practice Address - Street 1:27 MATTHEWS ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-1962
Practice Address - Country:US
Practice Address - Phone:845-294-5124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108154101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)