Basic Information
| Provider Information | |||||||||
| NPI: | 1629261292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINASSIAN | ||||||||
| FirstName: | SUSANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1540 E COLORADO ST | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912051514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182447257 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1540 E COLORADO ST | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912051514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182447257 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 08/08/2012 | ||||||||
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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 | 225C00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 390200000X | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 7068 | 05 | CA | MEDICAID | 7420 | 05 | CA | MEDICAID |