Basic Information
Provider Information | |||||||||
NPI: | 1174583256 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DORSKY | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, PHD, LSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 201 MCKINLEY AVE | ||||||||
Address2: |   | ||||||||
City: | NEW LEXINGTON | ||||||||
State: | OH | ||||||||
PostalCode: | 437641434 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403423868 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1375 COMMERCE DR | ||||||||
Address2: |   | ||||||||
City: | NEW LEXINGTON | ||||||||
State: | OH | ||||||||
PostalCode: | 437649511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7404549766 | ||||||||
FaxNumber: | 7405886452 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S0013210 | OH | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 135901 | 01 | OH | MOUNT CARMEL PIN | OTHER |