Provider Demographics
NPI:1659420594
Name:ANVIN, SUSAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:ANVIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1769 PARK AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2025
Mailing Address - Country:US
Mailing Address - Phone:408-294-9905
Mailing Address - Fax:408-692-9988
Practice Address - Street 1:1769 PARK AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2025
Practice Address - Country:US
Practice Address - Phone:408-294-9905
Practice Address - Fax:408-692-9988
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 21185103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent