Provider Demographics
NPI:1528605680
Name:BURGESS, SUSAN (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 THIMBLE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-5721
Mailing Address - Country:US
Mailing Address - Phone:203-815-8960
Mailing Address - Fax:
Practice Address - Street 1:2 CORPORATE DR STE 211
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-1376
Practice Address - Country:US
Practice Address - Phone:203-815-8960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4123101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty