=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225156425
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN FRUGONE MIZIKER MA, CCC-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6333 WILSHIRE BLVD SUITE 309
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-651-5107
-----------------------------------------------------
Fax | 323-651-4169
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4638 LEDGE AVE
-----------------------------------------------------
City | TOLUCA LAKE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91602-1536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-761-9100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AU1281
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------