Provider Demographics
NPI:1043548308
Name:XIONG, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:XIONG
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 1:1640 TYROL LN APT 106
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6688
Mailing Address - Country:US
Mailing Address - Phone:209-670-9607
Mailing Address - Fax:
Practice Address - Street 1:1640 TYROL LN APT 106
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6688
Practice Address - Country:US
Practice Address - Phone:209-670-9607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6198101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)