Healthcare Provider Details

I. General information

NPI: 1831147958
Provider Name (Legal Business Name): SUZANNE SOUTHWORTH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1327 18TH STREET NW
WASHINGTON DC
20036
US

IV. Provider business mailing address

9441 HOLBROOK LANE
POTOMAC MD
20854
US

V. Phone/Fax

Practice location:
  • Phone: 202-785-2400
  • Fax: 202-452-1853
Mailing address:
  • Phone: 301-983-9049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number03673
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY100143
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: