Provider Demographics
NPI:1821115684
Name:PHILO, SUSAN STEWART (ED M)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:STEWART
Last Name:PHILO
Suffix:
Gender:F
Credentials:ED M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 MISSION RD
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6329
Mailing Address - Country:US
Mailing Address - Phone:907-486-7688
Mailing Address - Fax:907-486-7687
Practice Address - Street 1:717 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6416
Practice Address - Country:US
Practice Address - Phone:907-481-2400
Practice Address - Fax:907-481-2419
Is Sole Proprietor?:No
Enumeration Date:2007-03-24
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK677101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health