Provider Demographics
NPI:1053903773
Name:TYRRELL, SUSAN MARIE (CRPA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:TYRRELL
Suffix:
Gender:F
Credentials:CRPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WILLOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-5882
Mailing Address - Country:US
Mailing Address - Phone:518-926-7200
Mailing Address - Fax:
Practice Address - Street 1:25 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-5882
Practice Address - Country:US
Practice Address - Phone:518-926-7200
Practice Address - Fax:518-926-7036
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care