Provider Demographics
NPI:1437767399
Name:SUN-SUSLOW, NI
Entity Type:Individual
Prefix:DR
First Name:NI
Middle Name:
Last Name:SUN-SUSLOW
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 1:1797 FOURTH ST
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-4347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 DICKINSON ST # B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2071
Practice Address - Country:US
Practice Address - Phone:831-219-8430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2021-12-23
Deactivation Date:2021-07-16
Deactivation Code:
Reactivation Date:2021-12-23
Provider Licenses
StateLicense IDTaxonomies
CA31784103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist