Provider Demographics
NPI:1528502630
Name:SUS
Entity type:Organization
Organization Name:SUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTAKE COORDINATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:K
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:13086
Authorized Official - Phone:212-369-7116
Mailing Address - Street 1:177 E122ND STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035
Mailing Address - Country:US
Mailing Address - Phone:212-360-7116
Mailing Address - Fax:
Practice Address - Street 1:177 E122ND STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035
Practice Address - Country:US
Practice Address - Phone:212-360-7116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13086251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health