Provider Demographics
NPI:1255471595
Name:BRIDGE-MOUNT, SUSAN J (MFT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
Last Name:BRIDGE-MOUNT
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:PO BOX 582
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95415-0582
Mailing Address - Country:US
Mailing Address - Phone:707-895-9080
Mailing Address - Fax:
Practice Address - Street 1:18151 MOUNTAIN VIEW ROAD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95415
Practice Address - Country:US
Practice Address - Phone:707-895-9080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 38541106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist