Provider Demographics
NPI:1760400485
Name:DUFFY, SUSIE (MFT)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:DUFFY
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 1:2501 LIGHTHOUSE LN
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1311
Mailing Address - Country:US
Mailing Address - Phone:949-887-9827
Mailing Address - Fax:
Practice Address - Street 1:1000 QUAIL ST
Practice Address - Street 2:SUITE 175
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2731
Practice Address - Country:US
Practice Address - Phone:949-887-9827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39983106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist