Provider Demographics
NPI:1295981694
Name:WILSON, SUZANNE CHERYL (PSYD)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:CHERYL
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3990 WESTERLY PL
Mailing Address - Street 2:SUITE 160
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2310
Mailing Address - Country:US
Mailing Address - Phone:949-922-4594
Mailing Address - Fax:
Practice Address - Street 1:3990 WESTERLY PL
Practice Address - Street 2:SUITE 160
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2310
Practice Address - Country:US
Practice Address - Phone:949-922-4594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355940OtherAGENCY MEDICAID ID
NY1285628552OtherAGENCY NPI
NYWVE061OtherAGENCY MEDICARE ID