Provider Demographics
NPI:1053415604
Name:WRIGHT, SUSAN (LCS2139)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:LCS2139
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 PRINCE ROYAL DR
Mailing Address - Street 2:CREATIVE LIFE CHANGE INSTITUTE
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925
Mailing Address - Country:US
Mailing Address - Phone:415-927-2748
Mailing Address - Fax:415-927-7948
Practice Address - Street 1:311 PRINCE ROYAL DR
Practice Address - Street 2:CREATIVE LIFE CHANGE INSTITUTE
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925
Practice Address - Country:US
Practice Address - Phone:415-927-2748
Practice Address - Fax:415-927-7948
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA341654554Medicaid
CA341654554Medicaid