Provider Demographics
NPI:1487827309
Name:TULLY-YOUNG, SUSAN (RNC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:TULLY-YOUNG
Suffix:
Gender:F
Credentials:RNC
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 1768
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-1768
Mailing Address - Country:US
Mailing Address - Phone:207-878-9663
Mailing Address - Fax:207-797-6137
Practice Address - Street 1:16 SAUNDERS WAY
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4833
Practice Address - Country:US
Practice Address - Phone:207-878-9663
Practice Address - Fax:207-797-6137
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERO34651163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent