Provider Demographics
NPI:1437296597
Name:PATLA, SUSHMA RANI (LMFT)
Entity Type:Individual
Prefix:MS
First Name:SUSHMA
Middle Name:RANI
Last Name:PATLA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:SUSHMA
Other - Middle Name:RANI
Other - Last Name:MADAHAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3636 GAMBLE OAK LANE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205
Mailing Address - Country:US
Mailing Address - Phone:510-921-4059
Mailing Address - Fax:209-451-1048
Practice Address - Street 1:800 SCENIC DRIVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-525-7339
Practice Address - Fax:209-558-4321
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2019-06-03
Deactivation Date:2019-04-21
Deactivation Code:
Reactivation Date:2019-06-03
Provider Licenses
StateLicense IDTaxonomies
CALMFT111093106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XOtherMENTAL HEALTH