Provider Demographics
NPI:1467786178
Name:EDWARDS, SUSANNE GRACE
Entity Type:Individual
Prefix:MS
First Name:SUSANNE
Middle Name:GRACE
Last Name:EDWARDS
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 1:18231 SHEPLEY PL
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-3219
Mailing Address - Country:US
Mailing Address - Phone:818-642-2502
Mailing Address - Fax:
Practice Address - Street 1:19231 VICTORY BLVD
Practice Address - Street 2:SUITE 554
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6308
Practice Address - Country:US
Practice Address - Phone:818-776-1755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA196856000Medicaid
CACMM70956FMedicaid