Provider Demographics
NPI:1487000295
Name:BURGIO, SUSAN (MS, RD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BURGIO
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 ALEXANDER AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-2618
Mailing Address - Country:US
Mailing Address - Phone:973-768-3328
Mailing Address - Fax:973-746-8005
Practice Address - Street 1:81 ALEXANDER AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-2618
Practice Address - Country:US
Practice Address - Phone:973-768-3328
Practice Address - Fax:973-746-8005
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
NJR540196133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist