Healthcare Provider Details

I. General information

NPI: 1992087795
Provider Name (Legal Business Name): SUSANNA ELIZABETH CZUCHRA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 MILLER AVENUE, STE C
MILL VALLEY CA
94941
US

IV. Provider business mailing address

295 MILLER AVENUE, STE C
MILL VALLEY CA
94941
US

V. Phone/Fax

Practice location:
  • Phone: 415-271-2171
  • Fax: 415-383-4465
Mailing address:
  • Phone: 415-271-2171
  • Fax: 415-383-4465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberCA 7057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: