Basic Information
Provider Information | |||||||||
NPI: | 1871673327 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CECERE | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | JENNIFER | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NEWMAN | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: | JENNIFER | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 15517 LAUREL RIDGE RD | ||||||||
Address2: |   | ||||||||
City: | MONTCLAIR | ||||||||
State: | VA | ||||||||
PostalCode: | 220251018 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7038784710 | ||||||||
FaxNumber: | 7037925699 | ||||||||
Practice Location | |||||||||
Address1: | 7969 ASHTON AVE | ||||||||
Address2: |   | ||||||||
City: | MANASSAS | ||||||||
State: | VA | ||||||||
PostalCode: | 201092885 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037927800 | ||||||||
FaxNumber: | 7037925699 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0701002654 | VA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 210245 | 01 | VA | BLUE CROSS BLUE SHIELD | OTHER |