Healthcare Provider Details

I. General information

NPI: 1336790211
Provider Name (Legal Business Name): SUSAN KUDRAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 JUDD AVE
BETHEL CT
06801-1538
US

IV. Provider business mailing address

35 JUDD AVE
BETHEL CT
06801-1538
US

V. Phone/Fax

Practice location:
  • Phone: 203-733-9103
  • Fax: 203-744-0801
Mailing address:
  • Phone: 203-733-9103
  • Fax: 203-744-0801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number000637
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: