Provider Demographics
NPI:1457343980
Name:SIROTY, SUSAN D (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:D
Last Name:SIROTY
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 1:1075 WASHINGTON ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WEST NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-2185
Mailing Address - Country:US
Mailing Address - Phone:617-965-1885
Mailing Address - Fax:
Practice Address - Street 1:1075 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEST NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02465-2185
Practice Address - Country:US
Practice Address - Phone:617-965-1885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7374102L00000X, 103T00000X, 103TA0700X, 103TC0700X, 103TC2200X, 103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7374OtherPSYCHOLOGIST