Provider Demographics
NPI:1619252400
Name:SIDWAY, SUSAN P (MS, LMFT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:P
Last Name:SIDWAY
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 WESTBURY PARK ROAD
Mailing Address - Street 2:SUITE 303E
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06795
Mailing Address - Country:US
Mailing Address - Phone:203-525-2091
Mailing Address - Fax:860-417-6099
Practice Address - Street 1:100 BANK STREET
Practice Address - Street 2:SUITE 306
Practice Address - City:SEYMOUR
Practice Address - State:CT
Practice Address - Zip Code:06483
Practice Address - Country:US
Practice Address - Phone:203-888-0462
Practice Address - Fax:203-888-1465
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001484106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist