Provider Demographics
NPI:1679736201
Name:DEOLIVEIRA, SUSAN FERNANDES (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:FERNANDES
Last Name:DEOLIVEIRA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 LONG WHARF DR
Mailing Address - Street 2:SUITE 321
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5991
Mailing Address - Country:US
Mailing Address - Phone:203-781-4600
Mailing Address - Fax:203-781-4624
Practice Address - Street 1:352 STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-3108
Practice Address - Country:US
Practice Address - Phone:203-781-4600
Practice Address - Fax:203-781-4624
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0094621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004082286Medicaid
CT008022626Medicaid
CT008066551OtherDEOLIVEIRA MEDICAID
CT500000315Medicaid
CT008066551OtherDEOLIVEIRA MEDICAID