Basic Information
| Provider Information | |||||||||
| NPI: | 1679800957 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ONDERWYZER | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 789 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037429200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15 OLD ROLLINSFORD RD STE 302 | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037429200 | ||||||||
| FaxNumber: | 6037424605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2009 | ||||||||
| LastUpdateDate: | 06/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 000180 | VT | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 089-0000155 | VT | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 2117 | NH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 3118595 | 05 | NH | MEDICAID |