Provider Demographics
NPI:1710171301
Name:REZIN, SUSAN (MC, LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:REZIN
Suffix:
Gender:F
Credentials:MC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 OLD GULCH RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-9499
Mailing Address - Country:US
Mailing Address - Phone:209-754-6846
Mailing Address - Fax:
Practice Address - Street 1:891 MOUNTAIN RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9713
Practice Address - Country:US
Practice Address - Phone:209-754-6846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCC-0676101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional