Provider Demographics
NPI:1891845905
Name:DISKIN, SUSAN DALE (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DALE
Last Name:DISKIN
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 1:2080 CENTURY PARK EAST
Mailing Address - Street 2:SUITE 1107
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067
Mailing Address - Country:US
Mailing Address - Phone:310-277-3990
Mailing Address - Fax:310-788-0560
Practice Address - Street 1:2080 CENTURY PARK EAST
Practice Address - Street 2:SUITE 1107
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067
Practice Address - Country:US
Practice Address - Phone:310-277-3990
Practice Address - Fax:310-788-0560
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7074103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP7074Medicare ID - Type Unspecified