Provider Demographics
NPI:1922103050
Name:MACKINNON, SUSAN MARY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARY
Last Name:MACKINNON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-1810
Mailing Address - Country:US
Mailing Address - Phone:732-628-0919
Mailing Address - Fax:732-846-8712
Practice Address - Street 1:328 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:METUCHEN
Practice Address - State:NJ
Practice Address - Zip Code:08840-2456
Practice Address - Country:US
Practice Address - Phone:732-906-6371
Practice Address - Fax:732-846-8712
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100281800103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMA893708Medicare ID - Type Unspecified