Healthcare Provider Details

I. General information

NPI: 1053835082
Provider Name (Legal Business Name): SUSAN GEORGE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 PROGRESSIVE DR STE 101
CHESAPEAKE VA
23320-2849
US

IV. Provider business mailing address

1210 PROGRESSIVE DR STE 101
CHESAPEAKE VA
23320-2849
US

V. Phone/Fax

Practice location:
  • Phone: 518-852-9691
  • Fax:
Mailing address:
  • Phone: 518-852-9691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008692
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: