Provider Demographics
NPI:1720246085
Name:KISBER, SUSIE (SUSIE KISBER PHD)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:KISBER
Suffix:
Gender:F
Credentials:SUSIE KISBER PHD
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:
Other - Last Name:KISBER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SUE KISBER PHD
Mailing Address - Street 1:1 SHIELDS AVE
Mailing Address - Street 2:CAPS
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5270
Mailing Address - Country:US
Mailing Address - Phone:530-752-0871
Mailing Address - Fax:
Practice Address - Street 1:1 SHIELDS AVE
Practice Address - Street 2:CAPS
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5270
Practice Address - Country:US
Practice Address - Phone:530-752-0871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20427103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical