Provider Demographics
NPI:1962424812
Name:PENZA-CLYVE, SUSAN MICHELLE (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MICHELLE
Last Name:PENZA-CLYVE
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 1:110 MARGINAL WAY # 285
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2442
Mailing Address - Country:US
Mailing Address - Phone:207-756-4278
Mailing Address - Fax:
Practice Address - Street 1:40 FOREST FALLS DR STE 316
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-7010
Practice Address - Country:US
Practice Address - Phone:207-756-4278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1193103TC0700X
MEPS 1193103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical