Provider Demographics
NPI:1154349140
Name:ALSUP, PATRICIA SUZANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:SUZANNE
Last Name:ALSUP
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 1:229 KEOKUK ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2773
Mailing Address - Country:US
Mailing Address - Phone:707-630-1789
Mailing Address - Fax:
Practice Address - Street 1:229 KEOKUK ST APT 2
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2773
Practice Address - Country:US
Practice Address - Phone:707-630-1789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12124103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL121240OtherBLUE SHIELD
CA0PL121240Medicare ID - Type UnspecifiedMEDICARE