Provider Demographics
NPI:1366075103
Name:MARCUS-MENDOZA, SUSAN TAFT (PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:TAFT
Last Name:MARCUS-MENDOZA
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 1:820 NANCY LYNN TER
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-4224
Mailing Address - Country:US
Mailing Address - Phone:405-627-1720
Mailing Address - Fax:
Practice Address - Street 1:3750 W MAIN ST STE AA
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4645
Practice Address - Country:US
Practice Address - Phone:405-627-1720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK655103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist