=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295849362
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSANN MARIE ADAMS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 02/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11201 BENTON ST
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92357-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-825-7084
-----------------------------------------------------
Fax | 909-777-3226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2304
-----------------------------------------------------
City | PALM DESERT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92261-2304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-825-7084
-----------------------------------------------------
Fax | 909-777-3326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 10825
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------