Basic Information
| Provider Information | |||||||||
| NPI: | 1811043128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEOGHEGAN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | GREENWELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREENWELL | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | CAROL | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6003 TAYLOR RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450691988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137779588 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 28208 STATE ROAD 1 | ||||||||
| Address2: | |||||||||
| City: | WEST HARRISON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470609686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125761600 | ||||||||
| FaxNumber: | 8125761602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2007 | ||||||||
| LastUpdateDate: | 05/28/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 4730 | OH | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 0826 | KY | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 20042311A | IN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 183465000 | 01 | OH | MAGELLAN | OTHER | 000000003586 | 01 | OH | ANTHEM | OTHER |