Healthcare Provider Details

I. General information

NPI: 1366655565
Provider Name (Legal Business Name): SUSAN J. VIG PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 PELHAM PKWY S KENNEDY CENTER CERC
BRONX NY
10461-1116
US

IV. Provider business mailing address

1410 PELHAM PKWY S KENNEDY CENTER CERC
BRONX NY
10461-1116
US

V. Phone/Fax

Practice location:
  • Phone: 718-430-8514
  • Fax: 718-892-2296
Mailing address:
  • Phone: 718-430-8514
  • Fax: 718-892-2296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number7874
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: