Provider Demographics
NPI:1790025963
Name:WHITEBREAD, SUSAN MARIE
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:WHITEBREAD
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 1:1070 POTRO DR # B
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-3321
Mailing Address - Country:US
Mailing Address - Phone:408-802-7173
Mailing Address - Fax:
Practice Address - Street 1:1070 POTRO AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048
Practice Address - Country:US
Practice Address - Phone:408-802-7173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV225400000XMedicaid