Provider Demographics
NPI:1992019699
Name:BONZO, SUZAN L
Entity Type:Individual
Prefix:
First Name:SUZAN
Middle Name:L
Last Name:BONZO
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 1:1004 FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-2409
Mailing Address - Country:US
Mailing Address - Phone:602-281-0729
Mailing Address - Fax:
Practice Address - Street 1:5620 BIRDCAGE ST STE 230
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610
Practice Address - Country:US
Practice Address - Phone:916-305-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-30881103K00000X
FL246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical