Healthcare Provider Details

I. General information

NPI: 1174635544
Provider Name (Legal Business Name): E SUSAN BIBBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6621 E PACIFIC COAST HWY STE 220
LONG BEACH CA
90803-4239
US

IV. Provider business mailing address

6621 E PACIFIC COAST HWY STE 220
LONG BEACH CA
90803-4239
US

V. Phone/Fax

Practice location:
  • Phone: 562-858-0663
  • Fax: 562-596-6443
Mailing address:
  • Phone: 562-858-0663
  • Fax: 562-596-6443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS8173
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: