Provider Demographics
NPI:1588952923
Name:ROBERTS, SUSAN (DI)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-2247
Mailing Address - Country:US
Mailing Address - Phone:908-812-0709
Mailing Address - Fax:888-214-9951
Practice Address - Street 1:68 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-2247
Practice Address - Country:US
Practice Address - Phone:908-812-0709
Practice Address - Fax:888-214-9951
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ541838103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst