Basic Information
| Provider Information | |||||||||
| NPI: | 1184649527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAMRON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | WILSON | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | ESTELLE | ||||||||
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| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | VA MEDICAL CENTER 11201 BENTON ST | ||||||||
| Address2: | BEHAVIORAL MEDICINE 116B | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | VA MEDICAL CENTER 11201 BENTON ST | ||||||||
| Address2: | BEHAVIORAL MEDICINE 116B | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | PSY 6232 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.