Provider Demographics
NPI:1336478643
Name:SURDAM, JOYCE
Entity Type:Individual
Prefix:DR
First Name:JOYCE
Middle Name:
Last Name:SURDAM
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:JOYCE
Other - Middle Name:
Other - Last Name:SURDAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, PSYCHOLOGIST
Mailing Address - Street 1:140 E BROADWAY AVE STE B-13
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-8632
Mailing Address - Country:US
Mailing Address - Phone:307-690-7870
Mailing Address - Fax:
Practice Address - Street 1:1277 N 15TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2343
Practice Address - Country:US
Practice Address - Phone:307-742-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY136103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical