Provider Demographics
NPI:1659495588
Name:PHILLIPS, SUSAN D (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:D
Last Name:PHILLIPS
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 1:12 SUMAC HOLW
Mailing Address - Street 2:
Mailing Address - City:VOORHEESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12186-5130
Mailing Address - Country:US
Mailing Address - Phone:518-765-2305
Mailing Address - Fax:
Practice Address - Street 1:12 SUMAC HOLW
Practice Address - Street 2:
Practice Address - City:VOORHEESVILLE
Practice Address - State:NY
Practice Address - Zip Code:12186-5130
Practice Address - Country:US
Practice Address - Phone:518-765-2305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006722103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01661081Medicaid
NY01661081Medicaid