Provider Demographics
NPI:1841582269
Name:WAVEREK, SUZANNE E (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:E
Last Name:WAVEREK
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84350 ACQUA CT
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92203-2902
Mailing Address - Country:US
Mailing Address - Phone:760-888-7114
Mailing Address - Fax:
Practice Address - Street 1:51025 AVENIDA MENDOZA STE 201
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7409
Practice Address - Country:US
Practice Address - Phone:760-888-7114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT96227106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist