Provider Demographics
NPI:1679623540
Name:RYAN, SUSAN O'ROURKE I (MSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:O'ROURKE
Last Name:RYAN
Suffix:I
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 1:9 DAMONMILL SQ
Mailing Address - Street 2:SUITE 3-1A
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2858
Mailing Address - Country:US
Mailing Address - Phone:978-369-6669
Mailing Address - Fax:978-369-6669
Practice Address - Street 1:9 DAMONMILL SQ
Practice Address - Street 2:SUITE 3-1A
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2858
Practice Address - Country:US
Practice Address - Phone:978-369-6669
Practice Address - Fax:978-369-6669
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110575101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARY P23335Medicare ID - Type Unspecified