Basic Information
| Provider Information | |||||||||
| NPI: | 1134663693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERTIG | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16415 FOX VALLEY TER | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208533220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014619686 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1003 W 7TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013451002 | ||||||||
| FaxNumber: | 3015605558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2016 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0904013618 | VA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 20061 | MD | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 20061 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.