Provider Demographics
NPI:1710068861
Name:O'HARA, SUSANA KRIVATSY (PHD)
Entity Type:Individual
Prefix:MRS
First Name:SUSANA
Middle Name:KRIVATSY
Last Name:O'HARA
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:P.O. BOX 392
Mailing Address - Street 2:
Mailing Address - City:EASTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02642-0392
Mailing Address - Country:US
Mailing Address - Phone:508-255-4355
Mailing Address - Fax:508-255-4355
Practice Address - Street 1:55 HERITAGE HILL CIRCLE
Practice Address - Street 2:
Practice Address - City:EASTHAM
Practice Address - State:MA
Practice Address - Zip Code:02642-0392
Practice Address - Country:US
Practice Address - Phone:508-255-4355
Practice Address - Fax:508-255-4355
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2082103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW02460OtherBLUE CROSS/BLUE SHIELD
MA110081217AMedicaid