Provider Demographics
NPI:1962668384
Name:SU, COLLEEN MARIE
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:MARIE
Last Name:SU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:MARIE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16940 HIGHWAY 14
Mailing Address - Street 2:C-F
Mailing Address - City:MOJAVE
Mailing Address - State:CA
Mailing Address - Zip Code:93501-1238
Mailing Address - Country:US
Mailing Address - Phone:661-824-5020
Mailing Address - Fax:
Practice Address - Street 1:16940 HIGHWAY 14
Practice Address - Street 2:C-F
Practice Address - City:MOJAVE
Practice Address - State:CA
Practice Address - Zip Code:93501-1238
Practice Address - Country:US
Practice Address - Phone:661-824-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator