Provider Demographics
NPI:1982629218
Name:FOX, SUSAN TERESE (DACM, LAC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:TERESE
Last Name:FOX
Suffix:
Gender:F
Credentials:DACM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 TAMAL VISTA BOULEVARD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2017
Mailing Address - Country:US
Mailing Address - Phone:415-381-8500
Mailing Address - Fax:415-381-8558
Practice Address - Street 1:21 TAMAL VISTA BOULEVARD
Practice Address - Street 2:SUITE 175
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94904-2017
Practice Address - Country:US
Practice Address - Phone:415-381-8500
Practice Address - Fax:415-381-8558
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA8340171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist