Provider Demographics
NPI:1124119516
Name:EICK, SUSAN (PSYD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:EICK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3043 SMOKY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504-4347
Mailing Address - Country:US
Mailing Address - Phone:434-993-8124
Mailing Address - Fax:
Practice Address - Street 1:3712 OLD FOREST RD STE 500
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-6959
Practice Address - Country:US
Practice Address - Phone:434-385-0744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA081003103103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP60607OtherUPIN
VA004945441Medicaid
VA386224OtherANTHEM BLUE SHIELD