Provider Demographics
NPI:1801920715
Name:TALMAGE, SUSAN (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:TALMAGE
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 1:5052 HORSESHOE TRL
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-3324
Mailing Address - Country:US
Mailing Address - Phone:214-760-1964
Mailing Address - Fax:214-760-9505
Practice Address - Street 1:1412 MAIN ST
Practice Address - Street 2:STE 320
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75202-4014
Practice Address - Country:US
Practice Address - Phone:214-760-1964
Practice Address - Fax:214-760-9505
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-4635103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096639201Medicaid
TX096639201Medicaid