Basic Information
| Provider Information | |||||||||
| NPI: | 1619096104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLAD | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | RAFFERTY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAFFERTY-LACE | ||||||||
| OtherFirstName: | SUSIE | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S.W. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 361 | ||||||||
| Address2: | |||||||||
| City: | NEVADA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959590361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304780900 | ||||||||
| FaxNumber: | 5304780970 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 NEW MOHAWK RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NEVADA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959593244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304780900 | ||||||||
| FaxNumber: | 5304780970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 03/11/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 27179 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.