Provider Demographics
NPI:1619096104
Name:GLAD, SUSAN RAFFERTY (MSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:RAFFERTY
Last Name:GLAD
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:SUSIE
Other - Middle Name:ELIZABETH
Other - Last Name:RAFFERTY-LACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 361
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-0361
Mailing Address - Country:US
Mailing Address - Phone:530-478-0900
Mailing Address - Fax:530-478-0970
Practice Address - Street 1:138 NEW MOHAWK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-3244
Practice Address - Country:US
Practice Address - Phone:530-478-0900
Practice Address - Fax:530-478-0970
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27179101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health