Basic Information
| Provider Information | |||||||||
| NPI: | 1578833554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSGROVE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 W BENJAMIN HOLT DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952073839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094789862 | ||||||||
| FaxNumber: | 2094781938 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 W BENJAMIN HOLT DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952073839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094789862 | ||||||||
| FaxNumber: | 2094781938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2012 | ||||||||
| LastUpdateDate: | 01/09/2012 | ||||||||
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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 | 101Y00000X | CA | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor |
No ID Information.