Provider Demographics
NPI:1992189351
Name:TAVANO, SUZANNE KATHRYN (RN, PHD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:KATHRYN
Last Name:TAVANO
Suffix:
Gender:F
Credentials:RN, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 N SAN PEDRO RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4188
Mailing Address - Country:US
Mailing Address - Phone:925-286-5056
Mailing Address - Fax:
Practice Address - Street 1:20 N SAN PEDRO RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4188
Practice Address - Country:US
Practice Address - Phone:925-286-5056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9950103TC0700X
CAW213270163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health