Provider Demographics
NPI:1710135066
Name:PORRECA, SUZANNE (PHD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:PORRECA
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:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232-6086
Mailing Address - Country:US
Mailing Address - Phone:609-272-8580
Mailing Address - Fax:609-272-8707
Practice Address - Street 1:2500 ENGLISH CREEK AVE BLDG E
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TWP
Practice Address - State:NJ
Practice Address - Zip Code:08234-5549
Practice Address - Country:US
Practice Address - Phone:609-272-8580
Practice Address - Fax:609-272-8707
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3SI100458400103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ132356CB8Medicare PIN