Provider Demographics
NPI:1548423148
Name:MACDONALD, SUSAN THOMAS (MA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:THOMAS
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 ROBINSON RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4113
Mailing Address - Country:US
Mailing Address - Phone:415-419-7298
Mailing Address - Fax:
Practice Address - Street 1:103 MORRIS ST STE I
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3863
Practice Address - Country:US
Practice Address - Phone:415-419-7298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52256106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist