Provider Demographics
NPI:1922253327
Name:LANDES, SUSAN GRACE (PSYD MFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GRACE
Last Name:LANDES
Suffix:
Gender:F
Credentials:PSYD MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13620 LINCOLN WAY STE 370
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-3269
Mailing Address - Country:US
Mailing Address - Phone:530-888-9858
Mailing Address - Fax:
Practice Address - Street 1:13620 LINCOLN WAY STE 370
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-3269
Practice Address - Country:US
Practice Address - Phone:530-888-9858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25632106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist