Provider Demographics
NPI:1043439409
Name:CONKLIN, SUSAN JOAN (LICSW, BCD)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JOAN
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:LICSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01267-2700
Mailing Address - Country:US
Mailing Address - Phone:413-884-4129
Mailing Address - Fax:413-458-9181
Practice Address - Street 1:85 HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:MA
Practice Address - Zip Code:01267-2700
Practice Address - Country:US
Practice Address - Phone:413-884-4129
Practice Address - Fax:413-458-9181
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA100143171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0000PO1493Medicare UPIN