Healthcare Provider Details

I. General information

NPI: 1366403727
Provider Name (Legal Business Name): SUSAN BUNDY-MYROW PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 CENTER RD
WEST SENECA NY
14224-2238
US

IV. Provider business mailing address

822 CENTER RD
WEST SENECA NY
14224-2238
US

V. Phone/Fax

Practice location:
  • Phone: 716-675-6702
  • Fax:
Mailing address:
  • Phone: 716-675-6702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number0116551
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: