Provider Demographics
NPI:1225799257
Name:SHADYBROOK PSYCHOLOGICAL SERVICES PLLC
Entity Type:Organization
Organization Name:SHADYBROOK PSYCHOLOGICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:636-487-7654
Mailing Address - Street 1:2554 LEWISVILLE CLEMMONS RD STE 304
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8749
Mailing Address - Country:US
Mailing Address - Phone:636-487-7654
Mailing Address - Fax:
Practice Address - Street 1:2554 LEWISVILLE CLEMMONS RD STE 304
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8749
Practice Address - Country:US
Practice Address - Phone:636-487-7654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty