Provider Demographics
NPI:1215009865
Name:KLIM, SUSAN LIDELL (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LIDELL
Last Name:KLIM
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 1:435 NEW KARNER RD
Mailing Address - Street 2:HANOVER SQUARE
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205
Mailing Address - Country:US
Mailing Address - Phone:518-456-2060
Mailing Address - Fax:518-456-2361
Practice Address - Street 1:435 NEW KARNER RD
Practice Address - Street 2:HANOVER SQUARE
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205
Practice Address - Country:US
Practice Address - Phone:518-456-2060
Practice Address - Fax:518-456-2361
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008887103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY52913BMedicare ID - Type Unspecified