Basic Information
| Provider Information | |||||||||
| NPI: | 1962420844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANSOUR | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT 45412 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KORT | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 680 LANGSDORF DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928313702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148719264 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 680 LANGSDORF DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928313702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148719264 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 03/26/2018 | ||||||||
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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 | 106H00000X | LMFT45412 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.