Provider Demographics
NPI:1225128887
Name:STAHL, SUSAN GALE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:GALE
Last Name:STAHL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1679 MASS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138
Mailing Address - Country:US
Mailing Address - Phone:617-441-4000
Mailing Address - Fax:617-441-3030
Practice Address - Street 1:1679 MASS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138
Practice Address - Country:US
Practice Address - Phone:617-441-4000
Practice Address - Fax:617-441-3030
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8096103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW51168Medicare ID - Type Unspecified