Provider Demographics
NPI:1871652156
Name:SHORE-SUSLOWITZ, PAUL DAVID (EDD)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:DAVID
Last Name:SHORE-SUSLOWITZ
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 DWIGHT RD STE 303
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1761
Mailing Address - Country:US
Mailing Address - Phone:413-567-9993
Mailing Address - Fax:413-567-9993
Practice Address - Street 1:175 DWIGHT RD STE 303
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1761
Practice Address - Country:US
Practice Address - Phone:413-567-9993
Practice Address - Fax:413-567-9993
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2521103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1859480Medicaid
MAW02636Medicare ID - Type Unspecified