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General NPI Number Information
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NPI Number | 1871519520
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Entity Type | Individual
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Provider Name | SUSAN M FORTIER PSYD
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Gender | Female
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Dates
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Enumeration Date | 07/14/2006
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Last Update Date | 11/20/2015
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Provider Practice Location Address
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Address Line | 100 MANSFIELD AVE
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City | BURLINGTON
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State | VT
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Zip | 05401-3322
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Country | US
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Telephone | 802-734-5876
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Fax | 802-489-5294
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Provider Business Mailing Address
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Address Line | 100 MANSFIELD AVE
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City | BURLINGTON
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State | VT
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Zip | 05401-3322
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Country | US
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Telephone | 802-734-5876
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Fax | 802-489-5294
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0700X
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Taxonomy Name | Adult Development & Aging Psychologist
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License Number | 0480000609
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License Number State | VT
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