Provider Demographics
NPI:1851474043
Name:PAULY, SUSAN L (PHD HSPP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:PAULY
Suffix:
Gender:F
Credentials:PHD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132A S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4770
Mailing Address - Country:US
Mailing Address - Phone:812-335-0605
Mailing Address - Fax:812-335-0606
Practice Address - Street 1:1132A S ROGERS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4770
Practice Address - Country:US
Practice Address - Phone:812-335-0605
Practice Address - Fax:812-335-0606
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041215A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2027007OtherCIGNA PIN #
IN548896POtherSIHO PIN #
INNON-PAROtherANTHEM PIN#
IN0007851384OtherAETNA PIN#