Provider Demographics
NPI:1376748814
Name:LEAVENWORTH, SUSAN G (PHD)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:G
Last Name:LEAVENWORTH
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 1:6450 DUTCHMANS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3338
Mailing Address - Country:US
Mailing Address - Phone:502-895-9900
Mailing Address - Fax:502-895-9901
Practice Address - Street 1:6450 DUTCHMANS PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3338
Practice Address - Country:US
Practice Address - Phone:502-895-9900
Practice Address - Fax:502-895-9901
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1095103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY11351412OtherCAQH