Provider Demographics
NPI:1376604512
Name:WISER, SUSAN LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LYNN
Last Name:WISER
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 1:301 ASSEMBLY DR UNIT 596
Mailing Address - Street 2:
Mailing Address - City:MONTREAT
Mailing Address - State:NC
Mailing Address - Zip Code:28757-8031
Mailing Address - Country:US
Mailing Address - Phone:607-279-3916
Mailing Address - Fax:
Practice Address - Street 1:121 W COURT ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4105
Practice Address - Country:US
Practice Address - Phone:607-279-3916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014437103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical