Provider Demographics
NPI:1669504171
Name:KENNETH R. SUCKERMAN, PH.D., P.A.
Entity Type:Organization
Organization Name:KENNETH R. SUCKERMAN, PH.D., P.A.
Other - Org Name:EAST BRUNSWICK PSYCHOLOGICAL ASSSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:SUCKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:732-238-9400
Mailing Address - Street 1:G9 BRIER HILL CT
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3338
Mailing Address - Country:US
Mailing Address - Phone:732-238-9400
Mailing Address - Fax:
Practice Address - Street 1:G9 BRIER HILL CT
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3338
Practice Address - Country:US
Practice Address - Phone:732-238-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-10
Last Update Date:2007-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00138800103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SU 636882Medicare ID - Type Unspecified