Provider Demographics
NPI:1558306852
Name:REBILLET, SUSAN B (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:B
Last Name:REBILLET
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 1:2610 ALLEN ST
Mailing Address - Street 2:SUITE 1601
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2500
Mailing Address - Country:US
Mailing Address - Phone:214-789-4027
Mailing Address - Fax:
Practice Address - Street 1:6330 LYNDON B JOHNSON FWY
Practice Address - Street 2:SUITE 234
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6467
Practice Address - Country:US
Practice Address - Phone:214-789-4027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31766103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1518748-04Medicaid
TXTXB102105Medicare PIN