Basic Information
| Provider Information | |||||||||
| NPI: | 1164749032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544107 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544107 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2010 | ||||||||
| LastUpdateDate: | 10/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XM0800X | 4939 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | FHC70044F | 05 | CA | MEDICAID | FHC70042F | 05 | CA | MEDICAID | 4939 | 01 | CA | PROFESSIONAL LICENSE # | OTHER |