Healthcare Provider Details

I. General information

NPI: 1417868621
Provider Name (Legal Business Name): SUZANNE ALICIA WALSH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E OCEAN BLVD STE 638
LONG BEACH CA
90802-5077
US

IV. Provider business mailing address

740 S HARBOR BLVD UNIT 1010
SANTA ANA CA
92704-2337
US

V. Phone/Fax

Practice location:
  • Phone: 310-439-9924
  • Fax:
Mailing address:
  • Phone: 310-439-9924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number165140
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: