Provider Demographics
NPI:1639488109
Name:RYERSON, SUSAN GAIL (MSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:GAIL
Last Name:RYERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 BRIDLE TRAIL ROAD
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492
Mailing Address - Country:US
Mailing Address - Phone:781-453-2336
Mailing Address - Fax:
Practice Address - Street 1:1415 BEACON STREET
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446
Practice Address - Country:US
Practice Address - Phone:617-566-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211259101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health