Basic Information
| Provider Information | |||||||||
| NPI: | 1295921476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8180 CLEARVISTA PARKWAY | ||||||||
| Address2: | SUITE 230 ATTN SHERRY MUELLER | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462564649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217561 | ||||||||
| FaxNumber: | 3176217470 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 HILLCREST DRIVE | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460124305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652984600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2007 | ||||||||
| LastUpdateDate: | 08/03/2009 | ||||||||
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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 | 106H00000X | 35001153A | IN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 100270530A | 05 | IN | MEDICAID |