Provider Demographics
NPI:1366522195
Name:BLUE, SUSAN W (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:W
Last Name:BLUE
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 1:1208 WILDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-3865
Mailing Address - Country:US
Mailing Address - Phone:607-727-3903
Mailing Address - Fax:
Practice Address - Street 1:804 VALLEY PLZ
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1009
Practice Address - Country:US
Practice Address - Phone:607-797-1100
Practice Address - Fax:607-797-9514
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010357-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist