Basic Information
| Provider Information | |||||||||
| NPI: | 1346907961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHA | ||||||||
| FirstName: | SUSIE | ||||||||
| MiddleName: | PA | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 8TH ST | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955215770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268633 | ||||||||
| FaxNumber: | 7078268638 | ||||||||
| Practice Location | |||||||||
| Address1: | 3750 ROHNERVILLE ROAD | ||||||||
| Address2: | |||||||||
| City: | FORTUNA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077254477 | ||||||||
| FaxNumber: | 7077252978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2021 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 88689 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.