Healthcare Provider Details

I. General information

NPI: 1568191302
Provider Name (Legal Business Name): SUSAN ELISABETH BORDEAUX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 ATWOOD DR
NORTHAMPTON MA
01060-4266
US

IV. Provider business mailing address

75 SOUTH ST TRLR 25
BERNARDSTON MA
01337-9494
US

V. Phone/Fax

Practice location:
  • Phone: 413-773-1000
  • Fax: 413-774-1776
Mailing address:
  • Phone: 208-850-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN2331124
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: