Provider Demographics
NPI:1114923638
Name:BARTLETT, SUSAN (MA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BARTLETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 KANE ST
Mailing Address - Street 2:PROVIDER ENROLLMENT-ELLIE ATKINS
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-2110
Mailing Address - Country:US
Mailing Address - Phone:860-523-6421
Mailing Address - Fax:860-523-3701
Practice Address - Street 1:850 BOLTON RD # U-85
Practice Address - Street 2:
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06269-9020
Practice Address - Country:US
Practice Address - Phone:860-486-2629
Practice Address - Fax:860-486-5422
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000626231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004070496Medicaid
CT004070496Medicaid