Provider Demographics
NPI:1255152377
Name:TAN, SUSANA T
Entity type:Individual
Prefix:MRS
First Name:SUSANA
Middle Name:T
Last Name:TAN
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 1:1350 PRINCETON DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-1256
Mailing Address - Country:US
Mailing Address - Phone:626-363-3826
Mailing Address - Fax:
Practice Address - Street 1:1350 PRINCETON DR
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-1256
Practice Address - Country:US
Practice Address - Phone:626-363-3826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician