Provider Demographics
NPI:1942027321
Name:BRACKS, SUSANA STEPHANIE (ACSW)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:STEPHANIE
Last Name:BRACKS
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:SUSANA
Other - Middle Name:STEPHANIE
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:408 BURCHETT ST UNIT 15
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1355
Mailing Address - Country:US
Mailing Address - Phone:909-542-4414
Mailing Address - Fax:
Practice Address - Street 1:1010 N CENTRAL AVE # 310
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2937
Practice Address - Country:US
Practice Address - Phone:818-724-9770
Practice Address - Fax:818-484-2991
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123340104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker