Provider Demographics
NPI:1780660431
Name:TAUB, SUSAN ILENE (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ILENE
Last Name:TAUB
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 1:1604 E OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2151
Mailing Address - Country:US
Mailing Address - Phone:423-928-2222
Mailing Address - Fax:423-926-5455
Practice Address - Street 1:1604 E OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2151
Practice Address - Country:US
Practice Address - Phone:423-928-2222
Practice Address - Fax:423-926-5455
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001182103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0005354369OtherAETNA
82899OtherBCBS
SD3689675Medicaid
014511OtherVALUE OPTIONS
3689675OtherCIGNA BH
82899OtherBCBS