Provider Demographics
NPI:1053788646
Name:CODY, SUSAN (HEALTH CARE PROVIDER)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:CODY
Suffix:
Gender:F
Credentials:HEALTH CARE PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9525 SMOKE TREE AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7257
Mailing Address - Country:US
Mailing Address - Phone:714-955-1163
Mailing Address - Fax:
Practice Address - Street 1:23162 LOS ALISOS BLVD
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2843
Practice Address - Country:US
Practice Address - Phone:949-544-9654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1352225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist