Provider Demographics
NPI:1568514875
Name:WEGENER, SUSAN YORK (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:YORK
Last Name:WEGENER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:YORK
Other - Last Name:TRAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 CELOSIA
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-1018
Mailing Address - Country:US
Mailing Address - Phone:609-906-2000
Mailing Address - Fax:949-713-2349
Practice Address - Street 1:12 CELOSIA
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-1018
Practice Address - Country:US
Practice Address - Phone:609-906-2000
Practice Address - Fax:949-713-2349
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASW206291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW20629Medicare PIN
CAQ46184Medicare UPIN