Provider Demographics
NPI:1942589312
Name:WARREN, SUSAN DAVIS (MT-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DAVIS
Last Name:WARREN
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WINDY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:MA
Mailing Address - Zip Code:01522-1412
Mailing Address - Country:US
Mailing Address - Phone:508-829-2626
Mailing Address - Fax:
Practice Address - Street 1:16 WINDY RIDGE RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:MA
Practice Address - Zip Code:01522-1412
Practice Address - Country:US
Practice Address - Phone:508-829-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACBMT# 04898225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist