Provider Demographics
NPI:1639328974
Name:BORITZ, SUSAN A (MA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:A
Last Name:BORITZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401A HERITAGE VLG
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-5708
Mailing Address - Country:US
Mailing Address - Phone:203-917-8585
Mailing Address - Fax:203-826-2211
Practice Address - Street 1:25 CHURCH HILL RD STE 201B
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-1646
Practice Address - Country:US
Practice Address - Phone:203-917-8585
Practice Address - Fax:203-826-2211
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000910101YA0400X
CT001240101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004257318Medicaid