Provider Demographics
NPI:1336245836
Name:SUDHALTER, VICKI (PHD)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:SUDHALTER
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 1:1050 FOREST HILL RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6356
Mailing Address - Country:US
Mailing Address - Phone:718-494-5182
Mailing Address - Fax:
Practice Address - Street 1:1050 FOREST HILL RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6356
Practice Address - Country:US
Practice Address - Phone:718-494-5182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011629-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01506394Medicaid
NY01506394Medicaid