Provider Demographics
NPI:1689659500
Name:SHNIDMAN, SUSAN R (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:R
Last Name:SHNIDMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SOMERSET RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-3519
Mailing Address - Country:US
Mailing Address - Phone:781-861-9132
Mailing Address - Fax:
Practice Address - Street 1:50 ROWE ST
Practice Address - Street 2:MELROSE MEDICAL CENTER, #700
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3201
Practice Address - Country:US
Practice Address - Phone:781-662-4380
Practice Address - Fax:781-665-4795
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA721103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW01422OtherBLUE CROSS & BLUE SHIELD
0004532476OtherAETNA INSURANCE CO.
MA710247OtherTUFTS HEALTH CARE
6170268OtherUNITED HEALTH CARE
MA0525618Medicaid
MA0525618Medicaid