Provider Demographics
NPI:1508865650
Name:DWYER, SUSAN ANN (PHD CLINICAL PSYCHOL)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ANN
Last Name:DWYER
Suffix:
Gender:F
Credentials:PHD CLINICAL PSYCHOL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 GLEN ELM DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9672
Mailing Address - Country:US
Mailing Address - Phone:260-413-0040
Mailing Address - Fax:
Practice Address - Street 1:203W WAYNE ST 317
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3610
Practice Address - Country:US
Practice Address - Phone:260-413-0040
Practice Address - Fax:260-344-2820
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041233103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200142310Medicaid
IN200142310Medicaid