Provider Demographics
NPI:1902473309
Name:BREDIMUS, SUSAN GAIL
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAIL
Last Name:BREDIMUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-6410
Mailing Address - Country:US
Mailing Address - Phone:480-321-5107
Mailing Address - Fax:480-321-5107
Practice Address - Street 1:954 W 16TH ST
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-6410
Practice Address - Country:US
Practice Address - Phone:480-321-5107
Practice Address - Fax:480-321-5107
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-05
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-0940101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)