Provider Demographics
NPI:1790707123
Name:SUSIC, PAUL LYNN (MA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:LYNN
Last Name:SUSIC
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 TRAILHEAD WAY
Mailing Address - Street 2:
Mailing Address - City:DARDENNE PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63368
Mailing Address - Country:US
Mailing Address - Phone:636-300-9922
Mailing Address - Fax:
Practice Address - Street 1:2451 EXECUTIVE DR. STE. 103
Practice Address - Street 2:
Practice Address - City:ST. CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303
Practice Address - Country:US
Practice Address - Phone:636-300-9922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01802103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service