Provider Demographics
NPI:1326413063
Name:OVERHAUSER, SUSAN MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:OVERHAUSER
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 1:3468 MT DIABLO BLVD STE B203
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-7120
Mailing Address - Country:US
Mailing Address - Phone:925-386-6062
Mailing Address - Fax:510-222-2090
Practice Address - Street 1:3468 MT DIABLO BLVD STE B203
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-7120
Practice Address - Country:US
Practice Address - Phone:925-386-6062
Practice Address - Fax:510-222-2090
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-07
Last Update Date:2019-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29951103TC2200X, 103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1326413063Medicaid