Basic Information
| Provider Information | |||||||||
| NPI: | 1225580723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRY VAN RHEENEN | ||||||||
| FirstName: | SUSAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 GROVE ST | ||||||||
| Address2: | |||||||||
| City: | NEVADA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959592602 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 138 NEW MOHAWK RD | ||||||||
| Address2: | |||||||||
| City: | NEVADA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959593244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304780900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2016 | ||||||||
| LastUpdateDate: | 11/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.