Provider Demographics
NPI:1255070405
Name:MALONEY, SUSAN LYNN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:MALONEY
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 1:20 CENTERPOINTE DR STE 130
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-2562
Mailing Address - Country:US
Mailing Address - Phone:657-325-8313
Mailing Address - Fax:
Practice Address - Street 1:20 CENTERPOINTE DR STE 130
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-2562
Practice Address - Country:US
Practice Address - Phone:657-325-8313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-AMTJLE175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist