Healthcare Provider Details

I. General information

NPI: 1679018915
Provider Name (Legal Business Name): SUSAN HEFNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2016
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 E WALNUT ST STE 117
PASADENA CA
91106-5129
US

IV. Provider business mailing address

1245 E WALNUT ST STE 117
PASADENA CA
91106-5129
US

V. Phone/Fax

Practice location:
  • Phone: 626-773-4364
  • Fax:
Mailing address:
  • Phone: 626-773-4364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1235671116
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2013593II
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: