Provider Demographics
NPI:1376618520
Name:SUSSKIND-WILDER, LANA N (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LANA
Middle Name:N
Last Name:SUSSKIND-WILDER
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 1:7323 N 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-8023
Mailing Address - Country:US
Mailing Address - Phone:602-410-9011
Mailing Address - Fax:480-922-5569
Practice Address - Street 1:9832 N HAYDEN RD
Practice Address - Street 2:SUITE 106
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-1298
Practice Address - Country:US
Practice Address - Phone:480-945-3475
Practice Address - Fax:480-922-5569
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3842103G00000X, 103T00000X, 103TA0700X, 103TC0700X, 103TB0200X, 103TF0200X, 103TP2701X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ60229OtherMEDICARE GROUP PIN
AZZ60229OtherMEDICARE GROUP PIN