Provider Demographics
NPI:1659707677
Name:KEATING, SURAYA SUSANA (MFT)
Entity Type:Individual
Prefix:MS
First Name:SURAYA
Middle Name:SUSANA
Last Name:KEATING
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 1:180 FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1805
Mailing Address - Country:US
Mailing Address - Phone:510-841-0888
Mailing Address - Fax:
Practice Address - Street 1:1924 4TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2697
Practice Address - Country:US
Practice Address - Phone:510-841-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43996106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist