Provider Demographics
NPI:1790886752
Name:WANGERMAN, SUSAN A (MA, LSW, LMHC)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:A
Last Name:WANGERMAN
Suffix:
Gender:F
Credentials:MA, LSW, LMHC
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:WANGERMAN
Other - Last Name:BERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2366
Mailing Address - Street 2:
Mailing Address - City:ORLEANS
Mailing Address - State:MA
Mailing Address - Zip Code:02653-6366
Mailing Address - Country:US
Mailing Address - Phone:508-255-3866
Mailing Address - Fax:508-255-3790
Practice Address - Street 1:25 CHASE LN
Practice Address - Street 2:
Practice Address - City:ORLEANS
Practice Address - State:MA
Practice Address - Zip Code:02653-3103
Practice Address - Country:US
Practice Address - Phone:508-255-3866
Practice Address - Fax:508-255-3790
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4068101YM0800X
MA3025778104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABC/BS OF MAOtherALL PRODUCTS
MA1895052Medicaid
MA354857OtherTRICARE/CHAMPUS
MA454542OtherTUFTS HEALTH