Provider Demographics
NPI:1760190276
Name:BURLAGE, SUSANNA MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:MARIE
Last Name:BURLAGE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 HEMLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL SPRINGS
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-2120
Mailing Address - Country:US
Mailing Address - Phone:856-669-9958
Mailing Address - Fax:
Practice Address - Street 1:114 HEMLOCK AVE
Practice Address - Street 2:
Practice Address - City:LAUREL SPRINGS
Practice Address - State:NJ
Practice Address - Zip Code:08021-2120
Practice Address - Country:US
Practice Address - Phone:856-669-9958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178018313101YP2500X
NJ37PC00628500101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional