Provider Demographics
NPI:1174516884
Name:HULL, SUSAN H (PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:HULL
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:PO BOX 3661
Mailing Address - Street 2:
Mailing Address - City:BANDERA
Mailing Address - State:TX
Mailing Address - Zip Code:78003-6661
Mailing Address - Country:US
Mailing Address - Phone:210-872-1713
Mailing Address - Fax:210-492-6418
Practice Address - Street 1:935 RIKKI DR
Practice Address - Street 2:
Practice Address - City:BANDERA
Practice Address - State:TX
Practice Address - Zip Code:78003-5925
Practice Address - Country:US
Practice Address - Phone:210-872-1713
Practice Address - Fax:210-492-6418
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-27
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX22945103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032630801Medicaid
TX032630801Medicaid
TX00D38RMedicare ID - Type Unspecified