Provider Demographics
NPI:1730224601
Name:ADUBATO, SUSAN ANN (PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:ADUBATO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BERGEN ST
Mailing Address - Street 2:ADMC 12 1205
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 BERGEN ST
Practice Address - Street 2:ADMC 1608
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3000
Practice Address - Country:US
Practice Address - Phone:973-972-7717
Practice Address - Fax:973-972-6556
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00226100103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1574701Medicaid
NJ655111Medicare PIN
NJ1574701Medicaid