Provider Demographics
NPI:1699816157
Name:MASSENZIO, SUSAN EVA (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:EVA
Last Name:MASSENZIO
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 1:260 CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-3526
Mailing Address - Country:US
Mailing Address - Phone:617-462-9297
Mailing Address - Fax:
Practice Address - Street 1:82 MARLBOROUGH ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116
Practice Address - Country:US
Practice Address - Phone:617-462-9297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2513103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWO3029OtherBLUECROSSBLUESHIELD