Healthcare Provider Details

I. General information

NPI: 1205987567
Provider Name (Legal Business Name): SUSAN ALICE COHEN BYRNE MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 OAK AVE SUITE B
DAVIS CA
95616-1000
US

IV. Provider business mailing address

1621 OAK AVE SUITE B
DAVIS CA
95616-1000
US

V. Phone/Fax

Practice location:
  • Phone: 530-753-0179
  • Fax:
Mailing address:
  • Phone: 530-753-0179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFT15818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: