Provider Demographics
NPI:1376722140
Name:CARMICHAEL, SUSAN K (MFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:CARMICHAEL
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 1:288 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5949
Mailing Address - Country:US
Mailing Address - Phone:909-981-0270
Mailing Address - Fax:909-981-3585
Practice Address - Street 1:288 W 9TH ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5949
Practice Address - Country:US
Practice Address - Phone:909-981-0270
Practice Address - Fax:909-981-3585
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 39104106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist