MEDICARE: DR. SUSAN D SIROTY PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	102L00000X	Psychoanalyst	7374	MA
2	103T00000X	Psychologist	7374	MA
3	103TA0700X	Adult Development & Aging Psychologist	7374	MA
4	103TC0700X	Clinical Psychologist	7374	MA
5	103TC2200X	Clinical Child & Adolescent Psychologist	7374	MA
6	103TP0814X	Psychoanalysis Psychologist	7374	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7374	OTHER	MA	PSYCHOLOGIST

General Provider Information

NPI Number	:	1457343980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN D SIROTY PSY.D.

Provider Business Mailing Address
First Line	:	1075 WASHINGTON ST
Second Line	:	SUITE 3
City	:	WEST NEWTON
State	:	MA
Zip	:	02465-2185
Country	:	US
Telephone Number	:	617-965-1885
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 WASHINGTON ST
Second Line	:
City	:	WEST NEWTON
State	:	MA
Zip	:	02465-2185
Country	:	US
Telephone Number	:	617-965-1885
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	11/01/2012

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