Provider Demographics
NPI:1992929236
Name:KO, SUSANNA (PHD)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:KO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:KO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1554 S SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3377
Mailing Address - Country:US
Mailing Address - Phone:310-949-9221
Mailing Address - Fax:
Practice Address - Street 1:1554 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3377
Practice Address - Country:US
Practice Address - Phone:310-949-9221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20183103TC0700X
NY015173103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical