Basic Information
| Provider Information | |||||||||
| NPI: | 1033296843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | NMI | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 S SUNWEST LN | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092524044 | ||||||||
| FaxNumber: | 9092524055 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 S SUNWEST LN | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092524044 | ||||||||
| FaxNumber: | 9092524055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 08/06/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT 19986 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | MFT19986 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.