Provider Demographics
NPI:1841571312
Name:TYBURCZY, SUSAN MERLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MERLE
Last Name:TYBURCZY
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 1:152 ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2952
Mailing Address - Country:US
Mailing Address - Phone:917-535-3177
Mailing Address - Fax:718-667-4350
Practice Address - Street 1:152 ROSS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2952
Practice Address - Country:US
Practice Address - Phone:917-535-3177
Practice Address - Fax:718-667-4350
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP75118103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical