Healthcare Provider Details

I. General information

NPI: 1609825934
Provider Name (Legal Business Name): SUSAN DIANE REUSSER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN DIANE REUSSER NEE TRICK LCSW

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 LAKE AVE VA-NIHCS
FT WAYNE IN
46805-5100
US

IV. Provider business mailing address

4201 MEDICAL DRIVE SUITE 280 STV HCS-HCHV BLUFFCREEK TOWERS
SAN ANTONIO TX
78229
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-5431
  • Fax: 260-460-1481
Mailing address:
  • Phone: 210-616-9915
  • Fax: 210-616-9710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003845A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: