Provider Demographics
NPI:1861650830
Name:STAHL, SUSAN MICHELLE (MFT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MICHELLE
Last Name:STAHL
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 1:1611 BOREL PL STE 211
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3505
Mailing Address - Country:US
Mailing Address - Phone:650-599-5845
Mailing Address - Fax:650-204-6836
Practice Address - Street 1:1611 BOREL PL STE 211
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3505
Practice Address - Country:US
Practice Address - Phone:650-599-5845
Practice Address - Fax:650-204-6836
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30126106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist