Provider Demographics
NPI:1063533446
Name:ADDIS, SUSAN T (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:T
Last Name:ADDIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 WILLIAMSON ROAD
Mailing Address - Street 2:PO BOX 4442
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117
Mailing Address - Country:US
Mailing Address - Phone:352-870-5302
Mailing Address - Fax:352-870-5302
Practice Address - Street 1:114 HATHAWAY LN UNIT 104
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6226
Practice Address - Country:US
Practice Address - Phone:352-870-5302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6526103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical