MEDICARE: DR. SUSAN MERLE TYBURCZY PH.D.

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	P75118	NY

General Provider Information

NPI Number	:	1841571312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN MERLE TYBURCZY PH.D.

Provider Business Mailing Address
First Line	:	152 ROSS AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-2952
Country	:	US
Telephone Number	:	917-535-3177
Fax Number	:	718-667-4350

Provider Business Practice Location Address
First Line	:	152 ROSS AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-2952
Country	:	US
Telephone Number	:	917-535-3177
Fax Number	:	718-667-4350

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

Provider Enumeration Date	:	08/29/2011
Last Update Date	:	08/29/2011

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