Provider Demographics
NPI:1417077553
Name:MAIN, SUSAN GAIL
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:GAIL
Last Name:MAIN
Suffix:
Gender:F
Credentials:
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 1492
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-7492
Mailing Address - Country:US
Mailing Address - Phone:916-765-2746
Mailing Address - Fax:916-624-0124
Practice Address - Street 1:3050 FITE CIR
Practice Address - Street 2:112
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-1806
Practice Address - Country:US
Practice Address - Phone:916-765-2746
Practice Address - Fax:916-624-0124
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator