Provider Demographics
NPI:1689056798
Name:POMMERVILLE, SUSAN K (MA, MFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:POMMERVILLE
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 W LANCASTER BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2303
Mailing Address - Country:US
Mailing Address - Phone:661-903-8822
Mailing Address - Fax:
Practice Address - Street 1:470 E 3RD ST STE C
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1630
Practice Address - Country:US
Practice Address - Phone:213-620-5712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT122862106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist