Provider Demographics
NPI:1740222876
Name:WEISS, SUSAN MYRNA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MYRNA
Last Name:WEISS
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 1:695 TRUMAN PKWY
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-3552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:695 TRUMAN PKWY
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3552
Practice Address - Country:US
Practice Address - Phone:617-361-4548
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4127103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04280Medicare ID - Type Unspecified