Provider Demographics
NPI:1619005626
Name:DAVIS, SUSAN MICHELE (LCSW, BCD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MICHELE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 N BEDFORD DR
Mailing Address - Street 2:#208
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4322
Mailing Address - Country:US
Mailing Address - Phone:310-274-2780
Mailing Address - Fax:310-274-4947
Practice Address - Street 1:416 N BEDFORD DR
Practice Address - Street 2:#208
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4322
Practice Address - Country:US
Practice Address - Phone:310-274-2780
Practice Address - Fax:310-274-4947
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 190871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCSW 019 00 NOtherBLUE SHIELD OF CALIFORNIA