Provider Demographics
NPI:1205906542
Name:BERRY, SUSAN (PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 HEBRON AVE
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033
Mailing Address - Country:US
Mailing Address - Phone:860-633-3006
Mailing Address - Fax:860-633-3328
Practice Address - Street 1:799 HEBRON AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-633-3006
Practice Address - Fax:860-633-3328
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001849103TC0700X
NY009058103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical