Provider Demographics
NPI:1578833554
Name:COSGROVE, SUSAN MARY
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARY
Last Name:COSGROVE
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 1:555 W BENJAMIN HOLT DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3839
Mailing Address - Country:US
Mailing Address - Phone:209-478-9862
Mailing Address - Fax:209-478-1938
Practice Address - Street 1:555 W BENJAMIN HOLT DR
Practice Address - Street 2:SUITE 400
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-3839
Practice Address - Country:US
Practice Address - Phone:209-478-9862
Practice Address - Fax:209-478-1938
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
171M00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor