Provider Demographics
NPI:1174635544
Name:BIBBY, E SUSAN
Entity Type:Individual
Prefix:
First Name:E
Middle Name:SUSAN
Last Name:BIBBY
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 1:6621 E PACIFIC COAST HWY STE 220
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-4239
Mailing Address - Country:US
Mailing Address - Phone:562-858-0663
Mailing Address - Fax:562-596-6443
Practice Address - Street 1:6621 E PACIFIC COAST HWY STE 220
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-4239
Practice Address - Country:US
Practice Address - Phone:562-858-0663
Practice Address - Fax:562-596-6443
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS81731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSW0813730Medicaid
CACSW0813730Medicaid