Provider Demographics
NPI:1154368330
Name:LEAR, SUSAN (PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LEAR
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:LEAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:708 FULLERTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:LEIGHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33974
Mailing Address - Country:US
Mailing Address - Phone:270-302-2600
Mailing Address - Fax:239-491-9038
Practice Address - Street 1:VIA TELEHEALTH
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301
Practice Address - Country:US
Practice Address - Phone:270-302-2600
Practice Address - Fax:229-491-9038
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 1333103TC0700X
KYKY0504106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000551121OtherANTHEM BLUE CROSS
000000551121OtherANTHEM BLUE CROSS