Provider Demographics
NPI:1639299951
Name:LAYNE, SUZANNE HADDAD (MA)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:HADDAD
Last Name:LAYNE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:SUZANNE
Other - Middle Name:LAYNE
Other - Last Name:HADDAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:9644 N 26TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-4707
Mailing Address - Country:US
Mailing Address - Phone:602-971-0533
Mailing Address - Fax:
Practice Address - Street 1:1900 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-6051
Practice Address - Country:US
Practice Address - Phone:602-764-8193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ582131Medicaid