Provider Demographics
NPI:1225269889
Name:KANESHIRO, SUSAN PATRICIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:PATRICIA
Last Name:KANESHIRO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:17451 BASTANCHURY RD
Mailing Address - Street 2:SUITE 204, OFFICE 21
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-1857
Mailing Address - Country:US
Mailing Address - Phone:714-404-7398
Mailing Address - Fax:888-958-5485
Practice Address - Street 1:17451 BASTANCHURY RD
Practice Address - Street 2:SUITE 204, OFFICE 21
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-1857
Practice Address - Country:US
Practice Address - Phone:714-404-7398
Practice Address - Fax:888-958-5485
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 22537103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical