Provider Demographics
NPI:1508996182
Name:VERREAULT, SUZANNE (PSYD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:VERREAULT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:
Other - Last Name:VERREAULT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:39 W ALTADENA DR
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-4733
Mailing Address - Country:US
Mailing Address - Phone:626-676-5434
Mailing Address - Fax:
Practice Address - Street 1:1126 N GRAND AVE
Practice Address - Street 2:SUITE D
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1551
Practice Address - Country:US
Practice Address - Phone:626-967-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21881103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical