Basic Information
| Provider Information | |||||||||
| NPI: | 1770955528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERTEL | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | B.A., ACCBC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 ARROWOOD DRIVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072842950 | ||||||||
| FaxNumber: | 7072842955 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 ARROWOOD DRIVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072842950 | ||||||||
| FaxNumber: | 7072842955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2015 | ||||||||
| LastUpdateDate: | 10/20/2015 | ||||||||
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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 | 101YA0400X | H0902181354 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.