Provider Demographics
NPI:1598217614
Name:SUSAN E DIETERICH PHD LLC
Entity Type:Organization
Organization Name:SUSAN E DIETERICH PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETERICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-635-2622
Mailing Address - Street 1:64 POST RD W
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4208
Mailing Address - Country:US
Mailing Address - Phone:203-635-2622
Mailing Address - Fax:
Practice Address - Street 1:64 POST RD W
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4208
Practice Address - Country:US
Practice Address - Phone:203-635-2622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002826261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health