Provider Demographics
NPI:1710104740
Name:BORDON, SUSAN MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MICHELLE
Last Name:BORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2332 BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-4603
Mailing Address - Country:US
Mailing Address - Phone:415-905-9443
Mailing Address - Fax:
Practice Address - Street 1:12011 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 408
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-4926
Practice Address - Country:US
Practice Address - Phone:310-905-9443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical