Provider Demographics
NPI:1518222488
Name:HANNON, SUSAN MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:HANNON
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 1:43890 SAN YSIDRO CIR
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3107
Mailing Address - Country:US
Mailing Address - Phone:760-773-6477
Mailing Address - Fax:
Practice Address - Street 1:14700 MANZANITA PARK RD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223
Practice Address - Country:US
Practice Address - Phone:951-845-3155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 201991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical