Provider Demographics
NPI:1881738284
Name:BROWN, SUSAN RACHEL (PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:RACHEL
Last Name:BROWN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 SHELTER COVE AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-2628
Mailing Address - Country:US
Mailing Address - Phone:530-753-9016
Mailing Address - Fax:530-765-6507
Practice Address - Street 1:1621 OAK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-1000
Practice Address - Country:US
Practice Address - Phone:530-753-0920
Practice Address - Fax:530-756-0636
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11944103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680311681OtherTIN
CAOPL119440Medicare ID - Type UnspecifiedMEDICARE PROVIDER#