Provider Demographics
NPI:1396803276
Name:BOARD, SUZILIENE AYANNA (PSYD)
Entity type:Individual
Prefix:DR
First Name:SUZILIENE
Middle Name:AYANNA
Last Name:BOARD
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 1:1788 WILMINGTON WEST CHESTER PIKE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342
Mailing Address - Country:US
Mailing Address - Phone:610-952-4558
Mailing Address - Fax:
Practice Address - Street 1:1788 WILMINGTON PIKE
Practice Address - Street 2:SUITE 107
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-8181
Practice Address - Country:US
Practice Address - Phone:610-952-4558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015303103TC0700X
PA9847267103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA109312HFHMedicare PIN