Provider Demographics
NPI:1184642811
Name:DIETERICH, SUSAN E (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:DIETERICH
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 1:64 POST RD W
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4208
Mailing Address - Country:US
Mailing Address - Phone:203-231-6188
Mailing Address - Fax:
Practice Address - Street 1:64 POST RD W
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4208
Practice Address - Country:US
Practice Address - Phone:203-231-6188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002826103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist