Provider Demographics
NPI:1275000978
Name:MARTIN, SUSAN (LMFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMFT
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 140514
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83714
Mailing Address - Country:US
Mailing Address - Phone:916-780-1059
Mailing Address - Fax:
Practice Address - Street 1:380 W. STATE ST.
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-629-7730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110172106H00000X
ID8352106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist