Healthcare Provider Details

I. General information

NPI: 1508865650
Provider Name (Legal Business Name): SUSAN ANN DWYER PHD CLINICAL PSYCHOL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203W WAYNE ST 317
FORT WAYNE IN
46802-3610
US

IV. Provider business mailing address

1702 GLEN ELM DR
FORT WAYNE IN
46845-9672
US

V. Phone/Fax

Practice location:
  • Phone: 260-413-0040
  • Fax: 260-344-2820
Mailing address:
  • Phone: 260-413-0040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20041233
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: