Provider Demographics
NPI:1295921476
Name:WILSON, SUZANNE D (LMFT)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8180 CLEARVISTA PARKWAY
Mailing Address - Street 2:SUITE 230 ATTN SHERRY MUELLER
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-4649
Mailing Address - Country:US
Mailing Address - Phone:317-621-7561
Mailing Address - Fax:317-621-7470
Practice Address - Street 1:2201 HILLCREST DRIVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-4305
Practice Address - Country:US
Practice Address - Phone:765-298-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001153A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530AMedicaid
IN100270530AMedicaid