Healthcare Provider Details

I. General information

NPI: 1053436915
Provider Name (Legal Business Name): SUSAN M FIELDSMITH LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 RED PONY RD.
WEST TISBURY MA
02575-1379
US

IV. Provider business mailing address

PO BOX 1379
WEST TISBURY MA
02575-1379
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-5300
  • Fax: 508-696-0003
Mailing address:
  • Phone: 508-693-5300
  • Fax: 508-696-0003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3336
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: