=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295921476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUZANNE D WILSON LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2007
-----------------------------------------------------
Last Update Date | 08/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2201 HILLCREST DRIVE
-----------------------------------------------------
City | ANDERSON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46012-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-298-4600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8180 CLEARVISTA PARKWAY SUITE 230 ATTN SHERRY MUELLER
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46256-4649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-621-7561
-----------------------------------------------------
Fax | 317-621-7470
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 35001153A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------