Basic Information
Provider Information | |||||||||
NPI: | 1144416074 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DICKSON | ||||||||
FirstName: | SUZANNE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 PARK STREET | ||||||||
Address2: | GLENS FALLS HOSPITAL - CREDENTIALING | ||||||||
City: | GLENS FALLS | ||||||||
State: | NY | ||||||||
PostalCode: | 128014413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5189265924 | ||||||||
FaxNumber: | 5189266983 | ||||||||
Practice Location | |||||||||
Address1: | 2 COUNTRY CLUB ROAD | ||||||||
Address2: | THE REHABILITATION & WELLNESS CENTER | ||||||||
City: | QUEENSBURY | ||||||||
State: | NY | ||||||||
PostalCode: | 12804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5189262000 | ||||||||
FaxNumber: | 5189262020 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2007 | ||||||||
LastUpdateDate: | 02/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 68 017333 | NY | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 017333 | 01 | NY | LICENSE | OTHER |