Provider Demographics
NPI:1124018742
Name:MOSCOV, SUSAN DREIFUS (MSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:DREIFUS
Last Name:MOSCOV
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 WILSHIRE BLVD
Mailing Address - Street 2:STE 306
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1421
Mailing Address - Country:US
Mailing Address - Phone:310-458-6643
Mailing Address - Fax:310-260-1181
Practice Address - Street 1:530 WILSHIRE BLVD
Practice Address - Street 2:STE 306
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1421
Practice Address - Country:US
Practice Address - Phone:310-458-6643
Practice Address - Fax:310-260-1181
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS91611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SW9161Medicare ID - Type Unspecified