Provider Demographics
NPI:1053445460
Name:WAX, SUSAN M (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:WAX
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 1:1010 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-1417
Mailing Address - Country:US
Mailing Address - Phone:805-965-5040
Mailing Address - Fax:805-965-5040
Practice Address - Street 1:1010 GARDEN ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-1417
Practice Address - Country:US
Practice Address - Phone:805-965-5040
Practice Address - Fax:805-965-5040
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10519103TC0700X, 103TF0000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103T00000XBehavioral Health & Social Service ProvidersPsychologist