Provider Demographics
NPI:1699980581
Name:MCKENZIE, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MCKENZIE
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 1:87 SWEETWATER DR
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-9397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:72 S MAIN ST
Practice Address - Street 2:SUITE 260
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-7161
Practice Address - Country:US
Practice Address - Phone:802-295-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT102L00000X, 103T00000X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TF0000X, 103TP0814X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1050263OtherCIGNA PROVIDER NUMBER
VT08018297OtherBC BS PROVIDER NUMBER