Provider Demographics
NPI:1083122972
Name:RO, SUSIE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:RO
Suffix:
Gender:F
Credentials:LCSW
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 53972
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92619-3972
Mailing Address - Country:US
Mailing Address - Phone:808-260-5705
Mailing Address - Fax:
Practice Address - Street 1:45445 PORTOLA AVE STE 1
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-4844
Practice Address - Country:US
Practice Address - Phone:760-385-3959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-13
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA799741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical