Provider Demographics
NPI:1780196147
Name:SHOTLAND, SUE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:SHOTLAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1241
Mailing Address - Country:US
Mailing Address - Phone:831-239-8421
Mailing Address - Fax:
Practice Address - Street 1:104 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3900
Practice Address - Country:US
Practice Address - Phone:831-423-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW76581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical