Healthcare Provider Details

I. General information

NPI: 1265147441
Provider Name (Legal Business Name): SUZANNE RACHEL IVERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15002 AMARGOSA RD
VICTORVILLE CA
92394-1868
US

IV. Provider business mailing address

16552 SUNHILL DR
VICTORVILLE CA
92395-4518
US

V. Phone/Fax

Practice location:
  • Phone: 442-255-4023
  • Fax:
Mailing address:
  • Phone: 760-780-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number142082
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: