Provider Demographics
NPI:1558754200
Name:TULLY, SUSANNAH (M ED)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:
Last Name:TULLY
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:SUSANNAH
Other - Middle Name:
Other - Last Name:TULLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:M ED
Mailing Address - Street 1:470 FORRESTER AVENUE
Mailing Address - Street 2:300
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101
Mailing Address - Country:US
Mailing Address - Phone:207-854-1030
Mailing Address - Fax:
Practice Address - Street 1:470 FOREST AVENUE
Practice Address - Street 2:300
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-854-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC4200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECC4200OtherMAINECARE