Provider Demographics
NPI:1285786202
Name:LIGHT, SUSAN EILEEN (PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:EILEEN
Last Name:LIGHT
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 1:1187 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94028
Mailing Address - Country:US
Mailing Address - Phone:650-321-2414
Mailing Address - Fax:
Practice Address - Street 1:1187 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94028
Practice Address - Country:US
Practice Address - Phone:650-321-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPY10357103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical