Provider Demographics
NPI:1245399518
Name:SUSSMAN, LEWIS R (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:R
Last Name:SUSSMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BROOKE ARMY MEDICAL CENTER
Mailing Address - Street 2:3551 ROGER BROOKE DRIVE
Mailing Address - City:JBSA FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234
Mailing Address - Country:US
Mailing Address - Phone:210-539-8798
Mailing Address - Fax:
Practice Address - Street 1:BROOKE ARMY MEDICAL CENTER
Practice Address - Street 2:3551 ROGER BROOKE DRIVE
Practice Address - City:JBSA FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:210-539-8798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH997103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1004243OtherMEDICAID
NH30422291Medicaid
VT1004243OtherMEDICAID
NH30422291Medicaid