Healthcare Provider Details

I. General information

NPI: 1386738094
Provider Name (Legal Business Name): SUSAN C MENGDEN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 HEIMER RD STE 400
SAN ANTONIO TX
78232-5032
US

IV. Provider business mailing address

140 HEIMER RD STE 400
SAN ANTONIO TX
78232-5032
US

V. Phone/Fax

Practice location:
  • Phone: 210-253-9763
  • Fax: 210-255-1681
Mailing address:
  • Phone: 210-253-9763
  • Fax: 210-255-1681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number25013
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: