Healthcare Provider Details

I. General information

NPI: 1912101692
Provider Name (Legal Business Name): SUSAN DICKEY BURLESON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN DICKEY BURLESON PH.D.

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 PROSPECT AVE
HARTFORD CT
06105-4276
US

IV. Provider business mailing address

66 LEMAY ST
WEST HARTFORD CT
06107-3025
US

V. Phone/Fax

Practice location:
  • Phone: 860-930-0021
  • Fax:
Mailing address:
  • Phone: 201-970-3644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2083
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4961
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number003157
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: