Basic Information
| Provider Information | |||||||||
| NPI: | 1417253485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORDUCH | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 547 SAW MILL RIVER RD | ||||||||
| Address2: | STE 1D | ||||||||
| City: | ARDSLEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105022154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128518102 | ||||||||
| FaxNumber: | 2125370102 | ||||||||
| Practice Location | |||||||||
| Address1: | 547 SAW MILL RIVER RD | ||||||||
| Address2: | STE 1D | ||||||||
| City: | ARDSLEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105022154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128518102 | ||||||||
| FaxNumber: | 2125370102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2011 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 014634-1 | NY | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 014634 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.