Healthcare Provider Details

I. General information

NPI: 1508349051
Provider Name (Legal Business Name): SUZANNE MARIE WILEY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 IRONWOOD LN
ANDERSON IN
46011-1651
US

IV. Provider business mailing address

607 IRONWOOD LN
ANDERSON IN
46011-1651
US

V. Phone/Fax

Practice location:
  • Phone: 765-400-5086
  • Fax:
Mailing address:
  • Phone: 765-400-5086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3224-6767
Identifier TypeOTHER
Identifier State
Identifier IssuerAPA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: