Provider Demographics
NPI:1093863144
Name:MASCOOP, SUSAN (EDD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MASCOOP
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 BLUE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-1155
Mailing Address - Country:US
Mailing Address - Phone:617-696-7236
Mailing Address - Fax:617-323-7301
Practice Address - Street 1:232 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-1155
Practice Address - Country:US
Practice Address - Phone:617-696-7236
Practice Address - Fax:617-323-7301
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6875103G00000X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50009OtherBLUE CROSS
MA0503339Medicaid
MA0503339Medicaid