Provider Demographics
NPI:1255574406
Name:FUSARO, SUSAN T (MASTERS)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:T
Last Name:FUSARO
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 612
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92661-0612
Mailing Address - Country:US
Mailing Address - Phone:949-400-2347
Mailing Address - Fax:
Practice Address - Street 1:102 E BAY AVE APT 2
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92661-1152
Practice Address - Country:US
Practice Address - Phone:949-400-2347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25017104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker