Provider Demographics
NPI:1598862575
Name:BLACK, SUSAN ESTHER (MFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ESTHER
Last Name:BLACK
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 1:2 SPRING LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-1429
Mailing Address - Country:US
Mailing Address - Phone:707-864-1600
Mailing Address - Fax:707-864-0855
Practice Address - Street 1:2 SPRING LN
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-1429
Practice Address - Country:US
Practice Address - Phone:707-864-1600
Practice Address - Fax:707-864-0855
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31281106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist