Provider Demographics
NPI:1639129604
Name:DICKINSON, SUSAN LOUISE (PSYCH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LOUISE
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-3825
Mailing Address - Country:US
Mailing Address - Phone:801-534-1006
Mailing Address - Fax:
Practice Address - Street 1:44 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1105
Practice Address - Country:US
Practice Address - Phone:801-584-8550
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTXXXXX-XXXXX103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool