Basic Information
| Provider Information | |||||||||
| NPI: | 1013043033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMIER | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | PAMELA | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1423 N JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658021917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172693465 | ||||||||
| FaxNumber: | 4172698189 | ||||||||
| Practice Location | |||||||||
| Address1: | 1423 N JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658021917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172696891 | ||||||||
| FaxNumber: | 4172695595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY01642 | MO | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 113666 | 01 | MO | BLUE SHIELD | OTHER |