Provider Demographics
NPI:1417288390
Name:DENNIS, SUSAN LEE (MFT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LEE
Last Name:DENNIS
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 1:1170 FIFE AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-3028
Mailing Address - Country:US
Mailing Address - Phone:650-322-5622
Mailing Address - Fax:650-322-5622
Practice Address - Street 1:165 ARCH ST
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-1303
Practice Address - Country:US
Practice Address - Phone:650-322-5622
Practice Address - Fax:650-323-2212
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-16
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46674106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist