Provider Demographics
NPI:1619090529
Name:FINE, SUSAN JO (LMFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JO
Last Name:FINE
Suffix:
Gender:F
Credentials:LMFT
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 1143
Mailing Address - Street 2:
Mailing Address - City:MOJAVE
Mailing Address - State:CA
Mailing Address - Zip Code:93502-1143
Mailing Address - Country:US
Mailing Address - Phone:661-824-3481
Mailing Address - Fax:
Practice Address - Street 1:2689 SIERRA HIGHWAY
Practice Address - Street 2:
Practice Address - City:ROSAMOND
Practice Address - State:CA
Practice Address - Zip Code:93560
Practice Address - Country:US
Practice Address - Phone:661-824-3481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20516106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist