Provider Demographics
NPI:1588115067
Name:SMITH, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
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 2099
Mailing Address - Street 2:
Mailing Address - City:KINGS BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:96143-2099
Mailing Address - Country:US
Mailing Address - Phone:530-546-5641
Mailing Address - Fax:
Practice Address - Street 1:8491 N. LAKE BLVD.
Practice Address - Street 2:
Practice Address - City:KINGS BEACH
Practice Address - State:CA
Practice Address - Zip Code:96143
Practice Address - Country:US
Practice Address - Phone:530-546-5641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)