Provider Demographics
NPI:1730117094
Name:FISHER, SUSAN JEANNE (PSYD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JEANNE
Last Name:FISHER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10921 WILSHIRE BLVD
Mailing Address - Street 2:STE 405
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4001
Mailing Address - Country:US
Mailing Address - Phone:310-824-7874
Mailing Address - Fax:
Practice Address - Street 1:10921 WILSHIRE BLVD
Practice Address - Street 2:STE 405
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4001
Practice Address - Country:US
Practice Address - Phone:310-824-7874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14546103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP14546Medicare ID - Type Unspecified