Provider Demographics
NPI:1275265118
Name:DEVER, SUSAN TERESA
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:TERESA
Last Name:DEVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:TERESA
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2330 LUDLOW AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA
Mailing Address - State:CA
Mailing Address - Zip Code:93428-4823
Mailing Address - Country:US
Mailing Address - Phone:805-459-3400
Mailing Address - Fax:
Practice Address - Street 1:2330 LUDLOW AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIA
Practice Address - State:CA
Practice Address - Zip Code:93428-4823
Practice Address - Country:US
Practice Address - Phone:805-459-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT34042101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional