Provider Demographics
NPI:1417464967
Name:MANNOS, SUSAN MICHELLE (LMFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MICHELLE
Last Name:MANNOS
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 1:25622 ADRIANA ST
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-3824
Mailing Address - Country:US
Mailing Address - Phone:949-338-1335
Mailing Address - Fax:
Practice Address - Street 1:6591 SUTTON ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-2116
Practice Address - Country:US
Practice Address - Phone:657-340-1005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-05
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF75648106H00000X
CA300049AP261QR0405X
CALMFT110222106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder