Healthcare Provider Details

I. General information

NPI: 1033157532
Provider Name (Legal Business Name): SUSAN ELLEN WAISBREN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE FEGAN 10
BOSTON MA
02115-5724
US

IV. Provider business mailing address

1 AUTUMN ST SUITE 525
BOSTON MA
02215-5393
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-4686
  • Fax: 617-730-0907
Mailing address:
  • Phone: 617-355-4686
  • Fax: 617-730-0907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 2749 PR
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: