Provider Demographics
NPI:1235160870
Name:WING, SUZANNE B (PHD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:B
Last Name:WING
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SUZANNE
Other - Middle Name:B
Other - Last Name:WING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:283 LAKEVIEW DR NE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-8869
Mailing Address - Country:US
Mailing Address - Phone:740-689-9609
Mailing Address - Fax:740-687-2725
Practice Address - Street 1:117 W MAIN ST STE 109
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3799
Practice Address - Country:US
Practice Address - Phone:740-689-9609
Practice Address - Fax:740-687-2725
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5439103T00000X, 103TC0700X
OH933626103TA0400X
OH103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH262480473027OtherCARESOURCE