Provider Demographics
NPI:1205138161
Name:TAYLOR, SUSANNE G (LMFT)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:G
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2809
Mailing Address - Country:US
Mailing Address - Phone:860-889-7711
Mailing Address - Fax:
Practice Address - Street 1:12 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2809
Practice Address - Country:US
Practice Address - Phone:860-899-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-29
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000618106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235942Medicaid