Provider Demographics
NPI:1164713855
Name:REARDON, SUSAN J (MA, LMHC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
Last Name:REARDON
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 DALE ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-2955
Mailing Address - Country:US
Mailing Address - Phone:781-642-7718
Mailing Address - Fax:
Practice Address - Street 1:316 DALE ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-2955
Practice Address - Country:US
Practice Address - Phone:781-642-7718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health