Healthcare Provider Details

I. General information

NPI: 1780282335
Provider Name (Legal Business Name): SUSAN M WARREN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MARTHA'S VINEYARD COMMUNITY SERVICES 111 EDGARTOWN RD
OAK BLUFFS MA
02557
US

IV. Provider business mailing address

132 SIDERS POND RD
FALMOUTH MA
02540-2665
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-7900
  • Fax: 508-693-7192
Mailing address:
  • Phone: 508-259-5294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMHC10001311
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: