Provider Demographics
NPI:1134521370
Name:SELF, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SELF
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 1:8292 E CORTEZ DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-5668
Mailing Address - Country:US
Mailing Address - Phone:623-680-5634
Mailing Address - Fax:480-661-9024
Practice Address - Street 1:13460 N 94TH DR
Practice Address - Street 2:SUITE J2
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4835
Practice Address - Country:US
Practice Address - Phone:623-487-7763
Practice Address - Fax:623-486-8276
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-0947101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional