Provider Demographics
NPI:1689870297
Name:PHILLIPS, SUZANNE BLANDINE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:BLANDINE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 NORWOOD RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3506
Mailing Address - Country:US
Mailing Address - Phone:631-757-6459
Mailing Address - Fax:
Practice Address - Street 1:22 NORWOOD RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3506
Practice Address - Country:US
Practice Address - Phone:631-757-6459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005431-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist