Healthcare Provider Details

I. General information

NPI: 1376244830
Provider Name (Legal Business Name): WSU PSYCHOLOGY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF PSYCHOLOGY-WSU PSYCHOLOGY CLINIC 1845 FAIRMOUNT STREET, JABARA HALL
WICHITA KS
67260
US

IV. Provider business mailing address

DEPARTMENT OF PSYCHOLOGY-WSU PSYCHOLOGY CLINIC 1845 FAIRMOUNT ST, JABARA HALL CAMPUS BOX 34
WICHITA KS
67260
US

V. Phone/Fax

Practice location:
  • Phone: 316-978-3170
  • Fax: 316-978-3086
Mailing address:
  • Phone: 316-978-3170
  • Fax: 316-978-3086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name: BRYCE SUMMERS
Title or Position: LP CLINIC DIRECTOR
Credential: PH.D.
Phone: 316-978-3170