Provider Demographics
NPI:1871760165
Name:NISSIM, SUSAN (LSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:NISSIM
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 MAPLE ST
Mailing Address - Street 2:ATTN AVAZQUEZ
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-4101
Mailing Address - Country:US
Mailing Address - Phone:732-324-8200
Mailing Address - Fax:
Practice Address - Street 1:288 RUES LN
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-5699
Practice Address - Country:US
Practice Address - Phone:732-257-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05385400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker