Basic Information
| Provider Information | |||||||||
| NPI: | 1265766851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEIL | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 49 RIDGEFIELD AVENUE | ||||||||
| Address2: | |||||||||
| City: | SOUTH SALEM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149497699 | ||||||||
| FaxNumber: | 9149493224 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 GREENRIDGE AVE | ||||||||
| Address2: | C/O ANDRUS CHILDREN'S CENTER | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106051201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149497680 | ||||||||
| FaxNumber: | 9149493224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2009 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 083016 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | WVE061 | 01 | NY | MEDICARE # | OTHER | 00355940 | 05 | NY | MEDICAID | 1285628552 | 01 | NY | ANDRUS AGENCY | OTHER |