Provider Demographics
NPI:1528182540
Name:ELIZONDO, SUSAN ANNETTE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANNETTE
Last Name:ELIZONDO
Suffix:
Gender:F
Credentials:
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 39A43
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-0043
Mailing Address - Country:US
Mailing Address - Phone:323-283-4255
Mailing Address - Fax:
Practice Address - Street 1:4700 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6082
Practice Address - Country:US
Practice Address - Phone:323-783-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist