Provider Demographics
NPI:1194066738
Name:STICH, SUSIE (RS6489)
Entity type:Individual
Prefix:MISS
First Name:SUSIE
Middle Name:
Last Name:STICH
Suffix:
Gender:F
Credentials:RS6489
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2494 LAKE TAHOE BLVD
Mailing Address - Street 2:B5
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-7719
Mailing Address - Country:US
Mailing Address - Phone:530-541-4594
Mailing Address - Fax:530-541-3144
Practice Address - Street 1:2494 LAKE TAHOE BLVD
Practice Address - Street 2:B-5
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7719
Practice Address - Country:US
Practice Address - Phone:530-541-4594
Practice Address - Fax:530-541-3144
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARS6489101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)