Provider Demographics
NPI:1467114819
Name:SUSTIN, STACIE (LMFT)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:SUSTIN
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 1:4774 PARK GRANADA UNIT 8043
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91372-7004
Mailing Address - Country:US
Mailing Address - Phone:424-354-9714
Mailing Address - Fax:
Practice Address - Street 1:660 HAMPSHIRE RD STE 200
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2557
Practice Address - Country:US
Practice Address - Phone:424-354-9714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100493106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist