Provider Demographics
NPI:1922390343
Name:WILBARN, SUSAUN R
Entity Type:Individual
Prefix:
First Name:SUSAUN
Middle Name:R
Last Name:WILBARN
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:PO BOX 2504
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-0504
Mailing Address - Country:US
Mailing Address - Phone:323-295-1504
Mailing Address - Fax:
Practice Address - Street 1:2160 W ADAMS BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-2039
Practice Address - Country:US
Practice Address - Phone:323-432-5185
Practice Address - Fax:323-432-5086
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator