Provider Demographics
NPI:1114065794
Name:SUSHELSKY, MAXINE (LMHC)
Entity Type:Individual
Prefix:MS
First Name:MAXINE
Middle Name:
Last Name:SUSHELSKY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1182
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02471-1182
Mailing Address - Country:US
Mailing Address - Phone:617-923-2882
Mailing Address - Fax:617-923-2162
Practice Address - Street 1:169 ELM ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-5356
Practice Address - Country:US
Practice Address - Phone:781-894-8440
Practice Address - Fax:781-894-1202
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6658101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health