MEDICARE: SUSANNAH CLAIRE TATE MSWI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	101YM0800X	Mental Health Counselor
2	390200000X	Student in an Organized Health Care Education/Training Program	CA
3	390200000X	Student in an Organized Health Care Education/Training Program
4	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1366011710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSANNAH CLAIRE TATE MSWI

Provider Business Mailing Address
First Line	:	408 CASSIDY ST STE 103
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-5316
Country	:	US
Telephone Number	:	760-439-4577
Fax Number	:

Provider Business Practice Location Address
First Line	:	408 CASSIDY ST STE 103
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-5316
Country	:	US
Telephone Number	:	760-439-4577
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2021
Last Update Date	:	03/30/2023

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