Healthcare Provider Details

I. General information

NPI: 1780660431
Provider Name (Legal Business Name): SUSAN ILENE TAUB PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 E OAKLAND AVE
JOHNSON CITY TN
37601-2151
US

IV. Provider business mailing address

1604 E OAKLAND AVE
JOHNSON CITY TN
37601-2151
US

V. Phone/Fax

Practice location:
  • Phone: 423-928-2222
  • Fax: 423-926-5455
Mailing address:
  • Phone: 423-928-2222
  • Fax: 423-926-5455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberP0000001182
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: