Provider Demographics
NPI:1174542666
Name:BLAINE, SUSAN LYNNE (MFT)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LYNNE
Last Name:BLAINE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 LAKE BLVD
Mailing Address - Street 2:SUITE 243
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-2614
Mailing Address - Country:US
Mailing Address - Phone:530-297-1601
Mailing Address - Fax:530-297-6864
Practice Address - Street 1:1260 LAKE BLVD
Practice Address - Street 2:SUITE 243
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-2614
Practice Address - Country:US
Practice Address - Phone:530-297-1601
Practice Address - Fax:530-297-6864
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC33852106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC33852OtherBBS LICENSE NUMBER