Provider Demographics
NPI:1134288269
Name:CHRISTOPHERSON, SUSAN (EDD)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:CHRISTOPHERSON
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 1:1 ELM SQ
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3643
Mailing Address - Country:US
Mailing Address - Phone:978-470-0520
Mailing Address - Fax:978-475-1181
Practice Address - Street 1:1 ELM SQ
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3643
Practice Address - Country:US
Practice Address - Phone:978-470-0520
Practice Address - Fax:978-475-1181
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6255103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50185Medicare ID - Type Unspecified