Provider Demographics
NPI:1124036439
Name:RISTINE, SUSANNAH F (EDD)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:F
Last Name:RISTINE
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 1:7 BLUE WAVE PROFESSIONAL CTR
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-7049
Mailing Address - Country:US
Mailing Address - Phone:207-985-3137
Mailing Address - Fax:207-985-2640
Practice Address - Street 1:7 BLUE WAVE PROFESSIONAL CTR
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-7049
Practice Address - Country:US
Practice Address - Phone:207-985-3137
Practice Address - Fax:207-985-2640
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS645103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM3903Medicare UPIN
MEMM3903Medicare ID - Type Unspecified