Provider Demographics
NPI:1417290073
Name:KAMINSKI, SUZANNE ELY (MED)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:ELY
Last Name:KAMINSKI
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 WALTHAM ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-8033
Mailing Address - Country:US
Mailing Address - Phone:781-761-5077
Mailing Address - Fax:781-862-4979
Practice Address - Street 1:1040 WALTHAM ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-8033
Practice Address - Country:US
Practice Address - Phone:781-761-5077
Practice Address - Fax:781-862-4979
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18633OtherBCBS
MA1004745OtherNHP
MA1303287OtherMBHP
MA1303287Medicaid
MA042611055OtherTAX ID
MA99618201OtherNETWORK HEALTH
MA0000023532OtherBMC
MA1303287Medicaid