Provider Demographics
NPI:1164749032
Name:FISHER, SUSAN (OTR/L)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4107
Mailing Address - Fax:831-454-4663
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-454-4107
Practice Address - Fax:831-454-4663
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4939225XM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70044FMedicaid
CAFHC70042FMedicaid
CA4939OtherPROFESSIONAL LICENSE #