Provider Demographics
NPI:1154540631
Name:COWAN, SUZAN E (ACSW)
Entity type:Individual
Prefix:
First Name:SUZAN
Middle Name:E
Last Name:COWAN
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BROADWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2649
Mailing Address - Country:US
Mailing Address - Phone:209-223-6412
Mailing Address - Fax:209-223-0920
Practice Address - Street 1:1001 BROADWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2649
Practice Address - Country:US
Practice Address - Phone:209-223-6412
Practice Address - Fax:209-223-0920
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW151211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAACSW15121OtherASSOC.CLINICAL SOCIAL WOR