Provider Demographics
NPI:1396280079
Name:HOLCOMB, SUSAN B (MA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:HOLCOMB
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 NAMASSIN RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22308-1043
Mailing Address - Country:US
Mailing Address - Phone:408-455-4837
Mailing Address - Fax:
Practice Address - Street 1:3880 S BASCOM AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-2674
Practice Address - Country:US
Practice Address - Phone:408-455-4837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42098106H00000X
VA0717001409106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist