Healthcare Provider Details

I. General information

NPI: 1942027321
Provider Name (Legal Business Name): SUSANA STEPHANIE BRACKS ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSANA STEPHANIE GONZALEZ

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N CENTRAL AVE # 310
GLENDALE CA
91202-2937
US

IV. Provider business mailing address

408 BURCHETT ST UNIT 15
GLENDALE CA
91203-1355
US

V. Phone/Fax

Practice location:
  • Phone: 818-724-9770
  • Fax: 818-484-2991
Mailing address:
  • Phone: 909-542-4414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number123340
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: