Provider Demographics
NPI:1225744402
Name:TULLY, SUSAN MARIE (LAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:TULLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:KENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 MILE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07930-2802
Mailing Address - Country:US
Mailing Address - Phone:973-229-5452
Mailing Address - Fax:
Practice Address - Street 1:9 BROADWAY STE 20
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2854
Practice Address - Country:US
Practice Address - Phone:862-259-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00548800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health