MEDICARE: MRS. SUSAN DIANE REUSSER LCSW

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	1041C0700X	Clinical Social Worker	34003845A	IN

General Provider Information

NPI Number	:	1609825934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN DIANE REUSSER LCSW

Provider Business Mailing Address
First Line	:	4201 MEDICAL DRIVE SUITE 280
Second Line	:	STV HCS-HCHV BLUFFCREEK TOWERS
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229
Country	:	US
Telephone Number	:	210-616-9915
Fax Number	:	210-616-9710

Provider Business Practice Location Address
First Line	:	2121 LAKE AVE
Second Line	:	VA-NIHCS
City	:	FT WAYNE
State	:	IN
Zip	:	46805-5100
Country	:	US
Telephone Number	:	260-426-5431
Fax Number	:	260-460-1481

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

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	12/07/2010

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