Provider Demographics
NPI:1699968644
Name:BENNETT, SUSAN M
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:BLODGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:280 E BROAD ST APT 912
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14604-1732
Mailing Address - Country:US
Mailing Address - Phone:978-651-1114
Mailing Address - Fax:978-373-6363
Practice Address - Street 1:280 E BROAD ST APT 912
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604-1732
Practice Address - Country:US
Practice Address - Phone:978-651-1114
Practice Address - Fax:978-372-6173
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011525101YP2500X
MA7875101YP2500X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1100952383Medicaid