Provider Demographics
NPI:1003971722
Name:VANDERSLICE, SUELLYN (PHD)
Entity Type:Individual
Prefix:
First Name:SUELLYN
Middle Name:
Last Name:VANDERSLICE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SUELLYN
Other - Middle Name:
Other - Last Name:VANDERSLICE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1202 CHRISTEL AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2030
Mailing Address - Country:US
Mailing Address - Phone:850-785-5325
Mailing Address - Fax:904-212-0170
Practice Address - Street 1:1202 CHRISTEL AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2030
Practice Address - Country:US
Practice Address - Phone:850-785-5325
Practice Address - Fax:904-212-0170
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 4182103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73429Medicare PIN