MEDICARE: SUSAN DALE DISKIN PHD

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	103TC0700X	Clinical Psychologist	PSY7074	CA

General Provider Information

NPI Number	:	1891845905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN DALE DISKIN PHD

Provider Business Mailing Address
First Line	:	2080 CENTURY PARK EAST
Second Line	:	SUITE 1107
City	:	LOS ANGELES
State	:	CA
Zip	:	90067
Country	:	US
Telephone Number	:	310-277-3990
Fax Number	:	310-788-0560

Provider Business Practice Location Address
First Line	:	2080 CENTURY PARK EAST
Second Line	:	SUITE 1107
City	:	LOS ANGELES
State	:	CA
Zip	:	90067
Country	:	US
Telephone Number	:	310-277-3990
Fax Number	:	310-788-0560

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	07/08/2007

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Directions to “ SUSAN DALE DISKIN PHD” Practice Location

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