Provider Demographics
NPI:1306129127
Name:DICKERSON KESSELLY, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DICKERSON KESSELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 RIDGE ST
Mailing Address - Street 2:APT 2
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-3701
Mailing Address - Country:US
Mailing Address - Phone:617-990-4168
Mailing Address - Fax:
Practice Address - Street 1:730 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5924
Practice Address - Country:US
Practice Address - Phone:781-395-0704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor