=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417003468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN WITENBERG FISHER PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 03/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 316 DELAWARE AVE SUITE 222
-----------------------------------------------------
City | DELMAR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12054-1932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-475-0142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 BIRCH HILL RD
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12211-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-434-6096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 007469
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------