Provider Demographics
NPI:1932597143
Name:KOHL, SUSAN B (LMHC, CASACT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:KOHL
Suffix:
Gender:F
Credentials:LMHC, CASACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4523
Mailing Address - Country:US
Mailing Address - Phone:518-952-8408
Mailing Address - Fax:518-952-8287
Practice Address - Street 1:1150 UNIVERSITY AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1647
Practice Address - Country:US
Practice Address - Phone:585-442-8422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YA0400X
NY007409101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid
NY03008239Medicaid