Basic Information
| Provider Information | |||||||||
| NPI: | 1760414965 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 PRATT ST | ||||||||
| Address2: | |||||||||
| City: | ESSEX | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064261122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607678025 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 LONG WHARF DR | ||||||||
| Address2: | SUITE 321 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814640 | ||||||||
| FaxNumber: | 2037814682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 06/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | E49199 | CT | Y | Nursing Service Providers | Registered Nurse | 163WA0400X | E49199 | CT | N | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No ID Information.