Provider Demographics
NPI:1346200193
Name:BREFACH, SUSAN M (EDD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:BREFACH
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:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-0003
Mailing Address - Country:US
Mailing Address - Phone:781-860-7211
Mailing Address - Fax:617-249-0446
Practice Address - Street 1:4 MILITIA DR
Practice Address - Street 2:SUITE 23
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-4737
Practice Address - Country:US
Practice Address - Phone:781-860-7211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4530103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW51162Medicare ID - Type Unspecified