Provider Demographics
NPI:1386948560
Name:BREEN, SUSAN (EDS)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:BREEN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85533-0152
Mailing Address - Country:US
Mailing Address - Phone:602-525-3686
Mailing Address - Fax:928-865-4966
Practice Address - Street 1:3555 E FRY BLVD
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2972
Practice Address - Country:US
Practice Address - Phone:520-515-2790
Practice Address - Fax:520-515-2726
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool