Provider Demographics
NPI:1558099903
Name:CHAVEZ, SUSANYELES Y
Entity Type:Individual
Prefix:
First Name:SUSANYELES
Middle Name:Y
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SUSANYELES
Other - Middle Name:
Other - Last Name:CHAVEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:709 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3202
Mailing Address - Country:US
Mailing Address - Phone:510-221-7160
Mailing Address - Fax:
Practice Address - Street 1:709 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3202
Practice Address - Country:US
Practice Address - Phone:510-221-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
CAMPSS-XARUCG175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor