Provider Demographics
NPI:1598086316
Name:GORTER, SUZANNE GRACE (MFT)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:GRACE
Last Name:GORTER
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 1:1455 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-1609
Mailing Address - Country:US
Mailing Address - Phone:805-235-5407
Mailing Address - Fax:
Practice Address - Street 1:956 WALNUT ST
Practice Address - Street 2:STE. 200J
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-1707
Practice Address - Country:US
Practice Address - Phone:805-235-5407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC#52869106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist