MEDICARE: DR. LYNDA SUSSMAN PHD CLINICAL PSYCHOL

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	103T00000X	Psychologist	PSY17987	CA
2	103TC2200X	Clinical Child & Adolescent Psychologist	PSY17987	CA
3	103TP2701X	Group Psychotherapy Psychologist	PSY17987	CA

General Provider Information

NPI Number	:	1447454905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYNDA SUSSMAN PHD CLINICAL PSYCHOL

Provider Business Mailing Address
First Line	:	1828 UNION STREET
Second Line	:
City	:	ALAMEDA
State	:	CA
Zip	:	94501
Country	:	US
Telephone Number	:	510-846-2737
Fax Number	:

Provider Business Practice Location Address
First Line	:	1652 TEXAS ST
Second Line	:	SUITE 236
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-6066
Country	:	US
Telephone Number	:	510-846-2737
Fax Number	:

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

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	06/02/2008

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