Provider Demographics
NPI:1699809327
Name:WHITE, SUSAN LEE (CATC-CAADE-040950)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LEE
Last Name:WHITE
Suffix:
Gender:F
Credentials:CATC-CAADE-040950
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E WASHINGTON ST
Mailing Address - Street 2:171
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-8133
Mailing Address - Country:US
Mailing Address - Phone:909-423-0471
Mailing Address - Fax:
Practice Address - Street 1:1076 SANTO ANTONIO DR
Practice Address - Street 2:SUITE B
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-8103
Practice Address - Country:US
Practice Address - Phone:909-433-9824
Practice Address - Fax:909-433-9830
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0040950101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)