Provider Demographics
NPI:1780053223
Name:MOSCHOS, SUSAN LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LYNN
Last Name:MOSCHOS
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-468-0300
Mailing Address - Fax:239-343-4257
Practice Address - Street 1:3501 HEALTH CENTER BLVD STE 2190
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:34135-8133
Practice Address - Country:US
Practice Address - Phone:239-468-0300
Practice Address - Fax:239-343-4257
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4541103TC2200X
FLPY10528103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116060600Medicaid