Provider Demographics
NPI:1104844190
Name:YODER, SUSAN K (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:K
Last Name:YODER
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 1:8170 SOUTH AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6434
Mailing Address - Country:US
Mailing Address - Phone:330-726-2965
Mailing Address - Fax:330-726-0449
Practice Address - Street 1:8170 SOUTH AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6413
Practice Address - Country:US
Practice Address - Phone:330-726-2965
Practice Address - Fax:330-726-0449
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4568103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0895858Medicaid
OH0895858Medicaid