MEDICARE: DR. SUSAN B REBILLET PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	31766	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558306852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN B REBILLET PHD

Provider Business Mailing Address
First Line	:	2610 ALLEN ST
Second Line	:	SUITE 1601
City	:	DALLAS
State	:	TX
Zip	:	75204-2500
Country	:	US
Telephone Number	:	214-789-4027
Fax Number	:

Provider Business Practice Location Address
First Line	:	6330 LYNDON B JOHNSON FWY
Second Line	:	SUITE 234
City	:	DALLAS
State	:	TX
Zip	:	75240-6467
Country	:	US
Telephone Number	:	214-789-4027
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	07/02/2010

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