Provider Demographics
NPI:1285914234
Name:KOTULSKY, SUSAN ELAINE (MA, LMFT)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELAINE
Last Name:KOTULSKY
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BULLARD ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3716
Mailing Address - Country:US
Mailing Address - Phone:203-615-4452
Mailing Address - Fax:
Practice Address - Street 1:49 JOHN ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1484
Practice Address - Country:US
Practice Address - Phone:203-307-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001469106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist