MEDICARE: MRS. SUSAN LEE WHITE CATC-CAADE-040950

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	0040950	CA

General Provider Information

NPI Number	:	1699809327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN LEE WHITE CATC-CAADE-040950

Provider Business Mailing Address
First Line	:	901 E WASHINGTON ST
Second Line	:	171
City	:	COLTON
State	:	CA
Zip	:	92324-8133
Country	:	US
Telephone Number	:	909-423-0471
Fax Number	:

Provider Business Practice Location Address
First Line	:	1076 SANTO ANTONIO DR
Second Line	:	SUITE B
City	:	COLTON
State	:	CA
Zip	:	92324-8103
Country	:	US
Telephone Number	:	909-433-9824
Fax Number	:	909-433-9830

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	07/08/2007

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