Provider Demographics
NPI:1568524999
Name:TULLY, SUSAN ENNS (MA,LMHC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ENNS
Last Name:TULLY
Suffix:
Gender:F
Credentials:MA,LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 N WICKHAM RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2369
Mailing Address - Country:US
Mailing Address - Phone:321-751-7000
Mailing Address - Fax:321-751-7055
Practice Address - Street 1:3040 N WICKHAM RD
Practice Address - Street 2:SUITE 10
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2369
Practice Address - Country:US
Practice Address - Phone:321-751-7000
Practice Address - Fax:321-751-7055
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5333101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health