Provider Demographics
NPI:1174832224
Name:WEIDIG, SUSAN B (MFT #41865)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:B
Last Name:WEIDIG
Suffix:
Gender:F
Credentials:MFT #41865
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2955
Mailing Address - Country:US
Mailing Address - Phone:310-546-6500
Mailing Address - Fax:310-546-9068
Practice Address - Street 1:2007 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2955
Practice Address - Country:US
Practice Address - Phone:310-546-6500
Practice Address - Fax:310-546-9068
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT #41865106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist