Provider Demographics
NPI:1710556188
Name:GERVAIS, SUSAN REANNE (ACSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:REANNE
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1287 OLIVE TREE LN APT A
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-5108
Mailing Address - Country:US
Mailing Address - Phone:951-385-8374
Mailing Address - Fax:
Practice Address - Street 1:1105 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4512
Practice Address - Country:US
Practice Address - Phone:951-436-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1077071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical