Provider Demographics
NPI:1255311718
Name:LACK, SUSANNA ANGELICA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSANNA
Middle Name:ANGELICA
Last Name:LACK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 ENGLE DR
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19086-6322
Mailing Address - Country:US
Mailing Address - Phone:610-565-5885
Mailing Address - Fax:
Practice Address - Street 1:211 N MONROE ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3019
Practice Address - Country:US
Practice Address - Phone:610-891-9923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008960103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical