MEDICARE: DR. SUSAN MARIE OVERHAUSER PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	29951	CA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	103TC0700X	Clinical Psychologist	29951	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326413063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN MARIE OVERHAUSER PH.D.

Provider Business Mailing Address
First Line	:	3468 MT DIABLO BLVD STE B203
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-7120
Country	:	US
Telephone Number	:	925-386-6062
Fax Number	:	510-222-2090

Provider Business Practice Location Address
First Line	:	3468 MT DIABLO BLVD STE B203
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-7120
Country	:	US
Telephone Number	:	925-386-6062
Fax Number	:	510-222-2090

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2015
Last Update Date	:	02/03/2019

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