Provider Demographics
NPI:1114392552
Name:SUSQUEHANNA PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:SUSQUEHANNA PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:STAUFFER
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:717-362-8900
Mailing Address - Street 1:PO BOX 739
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17023-0739
Mailing Address - Country:US
Mailing Address - Phone:717-362-8900
Mailing Address - Fax:717-362-8910
Practice Address - Street 1:20 CLEARFIELD STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETHVILLE
Practice Address - State:PA
Practice Address - Zip Code:17023-6603
Practice Address - Country:US
Practice Address - Phone:717-362-8900
Practice Address - Fax:717-362-8910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAP5006799L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016838420002Medicaid