Provider Demographics
NPI:1376244830
Name:WSU PSYCHOLOGY CLINIC
Entity Type:Organization
Organization Name:WSU PSYCHOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LP CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:316-978-3170
Mailing Address - Street 1:DEPARTMENT OF PSYCHOLOGY-WSU PSYCHOLOGY CLINIC
Mailing Address - Street 2:1845 FAIRMOUNT ST, JABARA HALL CAMPUS BOX 34
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67260
Mailing Address - Country:US
Mailing Address - Phone:316-978-3170
Mailing Address - Fax:316-978-3086
Practice Address - Street 1:DEPARTMENT OF PSYCHOLOGY-WSU PSYCHOLOGY CLINIC
Practice Address - Street 2:1845 FAIRMOUNT STREET, JABARA HALL
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67260
Practice Address - Country:US
Practice Address - Phone:316-978-3170
Practice Address - Fax:316-978-3086
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WICHITA STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty