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General NPI Number Information
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NPI Number | 1407011547
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Entity Type | Individual
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Provider Name | SUSAN EDELSTEIN PHD
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Gender | Female
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Dates
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Enumeration Date | 07/28/2008
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Last Update Date | 01/22/2021
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Provider Practice Location Address
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Address Line | 14 SUNVIEW AVE
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City | SAN ANSELMO
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State | CA
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Zip | 94960-1464
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Country | US
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Telephone | 415-302-2246
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3012
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City | SAN ANSELMO
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State | CA
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Zip | 94979-3012
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Country | US
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Telephone | 415-456-6785
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY14535
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License Number State | CA
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