Provider Demographics
NPI:1609098227
Name:MAYTORENA, SUSAN COOK (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:COOK
Last Name:MAYTORENA
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 1:629 S. WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314
Mailing Address - Country:US
Mailing Address - Phone:703-519-6770
Mailing Address - Fax:703-229-0801
Practice Address - Street 1:629 S. WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314
Practice Address - Country:US
Practice Address - Phone:703-519-6770
Practice Address - Fax:703-229-0801
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical