Provider Demographics
NPI:1871769406
Name:SUSIC PSYCHOLOGICAL CONSULTING, PC
Entity type:Organization
Organization Name:SUSIC PSYCHOLOGICAL CONSULTING, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SUSIC
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:636-300-9922
Mailing Address - Street 1:350 TRAILHEAD WAY
Mailing Address - Street 2:
Mailing Address - City:DARDENNE PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7588
Mailing Address - Country:US
Mailing Address - Phone:636-300-9922
Mailing Address - Fax:636-300-9924
Practice Address - Street 1:2451 EXECUTIVE DR STE 103
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-5606
Practice Address - Country:US
Practice Address - Phone:636-300-9922
Practice Address - Fax:636-300-9924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-04
Last Update Date:2008-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01802103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498592518Medicaid
MO498592518Medicaid