Basic Information
| Provider Information | |||||||||
| NPI: | 1407930506 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOMURE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952010779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093732800 | ||||||||
| FaxNumber: | 2093732878 | ||||||||
| Practice Location | |||||||||
| Address1: | 265 W. ST. CHARLES ST | ||||||||
| Address2: | STE #3 | ||||||||
| City: | SAN ANDREAS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 95249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097551400 | ||||||||
| FaxNumber: | 2097551430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 1041C0700X | 13656 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.