Provider Demographics
NPI:1629163159
Name:ABRAHAM, SUSAN GAIL (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAIL
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-3113
Mailing Address - Country:US
Mailing Address - Phone:603-357-3848
Mailing Address - Fax:603-357-4087
Practice Address - Street 1:196 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-3113
Practice Address - Country:US
Practice Address - Phone:603-357-3848
Practice Address - Fax:603-357-4087
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH85452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT7191Medicaid
VT7191Medicaid
RE7111Medicare ID - Type Unspecified