Healthcare Provider Details

I. General information

NPI: 1265474977
Provider Name (Legal Business Name): SUSANNA MILLER-PENCE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 1
SAN LUIS OBISPO CA
93409-8101
US

IV. Provider business mailing address

CALIFORNIA MENS COLONY P.O.BOX 8101
SAN LUIS OBISPO CA
93409-8101
US

V. Phone/Fax

Practice location:
  • Phone: 805-547-7900
  • Fax:
Mailing address:
  • Phone: 805-547-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR0370701
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW6435
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW28260
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: