Provider Demographics
NPI:1467609859
Name:SUPER, GERTRUDE ELLEN (MA)
Entity Type:Individual
Prefix:MS
First Name:GERTRUDE
Middle Name:ELLEN
Last Name:SUPER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 FELDSPAR AVE
Mailing Address - Street 2:
Mailing Address - City:BEACON FALLS
Mailing Address - State:CT
Mailing Address - Zip Code:06403-1439
Mailing Address - Country:US
Mailing Address - Phone:203-723-8772
Mailing Address - Fax:
Practice Address - Street 1:50 BROOKSIDE ROAD
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-1402
Practice Address - Country:US
Practice Address - Phone:203-755-4490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health