Provider Demographics
NPI:1407930506
Name:KOMURE, SUSAN MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:KOMURE
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:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-0779
Mailing Address - Country:US
Mailing Address - Phone:209-373-2800
Mailing Address - Fax:209-373-2878
Practice Address - Street 1:265 W. ST. CHARLES ST
Practice Address - Street 2:STE #3
Practice Address - City:SAN ANDREAS
Practice Address - State:CO
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:209-755-1400
Practice Address - Fax:209-755-1430
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical