Provider Demographics
NPI:1639184187
Name:GWALTNEY, SUSAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:GWALTNEY
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 1:7668 LA MANGA DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-3129
Mailing Address - Country:US
Mailing Address - Phone:972-701-8196
Mailing Address - Fax:972-392-3983
Practice Address - Street 1:7668 LA MANGA DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-3129
Practice Address - Country:US
Practice Address - Phone:972-701-8196
Practice Address - Fax:972-392-3983
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24096103TC0700X, 103TC2200X, 103TF0000X, 103TF0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist