Provider Demographics
NPI:1174868434
Name:SUOS, RODDY (PSYD)
Entity Type:Individual
Prefix:
First Name:RODDY
Middle Name:
Last Name:SUOS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 1/2 N LARCHMONT BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3014
Mailing Address - Country:US
Mailing Address - Phone:310-800-1442
Mailing Address - Fax:
Practice Address - Street 1:420 1/2 N LARCHMONT BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3014
Practice Address - Country:US
Practice Address - Phone:310-800-1442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26209103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical