1225156425 NPI number — MRS. SUSAN FRUGONE MIZIKER MA, CCC-A

Table of content: MRS. SUSAN FRUGONE MIZIKER MA, CCC-A (NPI 1225156425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225156425 NPI number — MRS. SUSAN FRUGONE MIZIKER MA, CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIZIKER
Provider First Name:
SUSAN
Provider Middle Name:
FRUGONE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, CCC-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FRUGONE
Provider Other First Name:
SUSAN
Provider Other Middle Name:
J.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, CCC-A
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1225156425
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4638 LEDGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLUCA LAKE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91602-1536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-761-9100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6333 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
SUITE 309
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90048-5702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-651-5107
Provider Business Practice Location Address Fax Number:
323-651-4169
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  AU1281 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GAU000320 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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