Provider Demographics
NPI:1679018915
Name:HEFNER, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HEFNER
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 1:1245 E WALNUT ST STE 117
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-5129
Mailing Address - Country:US
Mailing Address - Phone:626-773-4364
Mailing Address - Fax:
Practice Address - Street 1:1245 E WALNUT ST STE 117
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-5129
Practice Address - Country:US
Practice Address - Phone:626-773-4364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-22
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1235671116101YA0400X
171M00000X, 390200000X
CA2013593II101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1235671116OtherCCAPP