Provider Demographics
NPI:1659553386
Name:VILA, SUSANNE M
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:M
Last Name:VILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 FOUNDRY ST
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-1142
Mailing Address - Country:US
Mailing Address - Phone:304-455-2441
Mailing Address - Fax:304-455-3446
Practice Address - Street 1:333 FOUNDRY ST
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-1142
Practice Address - Country:US
Practice Address - Phone:304-455-2441
Practice Address - Fax:304-455-3446
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5332103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0889542000Medicaid