Provider Demographics
NPI:1518197094
Name:MCGAVIN, SUSANNE BARNES (MFT)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:BARNES
Last Name:MCGAVIN
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:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94953-0007
Mailing Address - Country:US
Mailing Address - Phone:415-846-2926
Mailing Address - Fax:
Practice Address - Street 1:3440 AIRWAY DR
Practice Address - Street 2:SUITE E
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2065
Practice Address - Country:US
Practice Address - Phone:707-544-3299
Practice Address - Fax:707-544-6837
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39738106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist