Provider Demographics
NPI:1265474977
Name:MILLER-PENCE, SUSANNA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSANNA
Middle Name:
Last Name:MILLER-PENCE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALIFORNIA MENS COLONY
Mailing Address - Street 2:P.O.BOX 8101
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93409-8101
Mailing Address - Country:US
Mailing Address - Phone:805-547-7900
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93409-8101
Practice Address - Country:US
Practice Address - Phone:805-547-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR03707011041C0700X
FLSW64351041C0700X
CALCSW282601041C0700X, 1041C0700X
VA09040061851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP27744Medicaid
NYP27744Medicaid