Provider Demographics
NPI:1073731337
Name:CULBERT, SUSAN L (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:CULBERT
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 1:21 VIGILANT ST
Mailing Address - Street 2:2
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-5126
Mailing Address - Country:US
Mailing Address - Phone:401-633-2800
Mailing Address - Fax:
Practice Address - Street 1:75 LAMBERT LIND HWY
Practice Address - Street 2:120-100
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1131
Practice Address - Country:US
Practice Address - Phone:401-681-4274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00939103T00000X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC2200X
VT048-0000730103T00000X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPS00939OtherLICENSED PSYCHOLOGIST
VT048-0000730OtherLICENSED PSYCHOLOGIST