Healthcare Provider Details

I. General information

NPI: 1295742492
Provider Name (Legal Business Name): SUSAN MALBOEUF PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238-002 KANAGAWA
YOKOSUKA KANAGAWA
96350
JP

IV. Provider business mailing address

PSC 475 BOX 1407
FPO AP
96350
JP

V. Phone/Fax

Practice location:
  • Phone: 315-243-4853
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY22959
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: