Healthcare Provider Details

I. General information

NPI: 1053445460
Provider Name (Legal Business Name): SUSAN M. WAX PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 GARDEN ST
SANTA BARBARA CA
93101-1417
US

IV. Provider business mailing address

1010 GARDEN ST
SANTA BARBARA CA
93101-1417
US

V. Phone/Fax

Practice location:
  • Phone: 805-965-5040
  • Fax: 805-965-5040
Mailing address:
  • Phone: 805-965-5040
  • Fax: 805-965-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY10519
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY10519
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY10519
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: