Provider Demographics
NPI:1720354491
Name:SURIYAKHAM, LINDA W (PHD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:W
Last Name:SURIYAKHAM
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 1:107 WILCOX RD
Mailing Address - Street 2:SUITE 107E
Mailing Address - City:STONINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06378-2614
Mailing Address - Country:US
Mailing Address - Phone:860-245-9222
Mailing Address - Fax:
Practice Address - Street 1:107 WILCOX RD
Practice Address - Street 2:SUITE 107 E
Practice Address - City:STONINGTON
Practice Address - State:CT
Practice Address - Zip Code:06378-2614
Practice Address - Country:US
Practice Address - Phone:860-245-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3158103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical