Provider Demographics
NPI:1811215650
Name:MERRY, SUSAN B (MA GLCMA DTR)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:B
Last Name:MERRY
Suffix:
Gender:F
Credentials:MA GLCMA DTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1444
Mailing Address - Country:US
Mailing Address - Phone:617-744-6180
Mailing Address - Fax:
Practice Address - Street 1:39 HILLSIDE RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-1444
Practice Address - Country:US
Practice Address - Phone:617-744-6180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst