Provider Demographics
NPI:1720537467
Name:ZACHARY SUSSMAN
Entity Type:Organization
Organization Name:ZACHARY SUSSMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:WROE
Authorized Official - Last Name:SUSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:303-564-8684
Mailing Address - Street 1:2501 WALNUT ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5752
Mailing Address - Country:US
Mailing Address - Phone:303-564-8684
Mailing Address - Fax:303-443-4682
Practice Address - Street 1:2501 WALNUT ST STE 104
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5752
Practice Address - Country:US
Practice Address - Phone:303-564-8684
Practice Address - Fax:303-443-4682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004443103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty