Provider Demographics
NPI:1942761432
Name:SUESCUN, RAQUEL PATRICIA (AMFT #109077)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:PATRICIA
Last Name:SUESCUN
Suffix:
Gender:F
Credentials:AMFT #109077
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 W VILLA ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-3348
Mailing Address - Country:US
Mailing Address - Phone:951-833-2260
Mailing Address - Fax:
Practice Address - Street 1:16360 ROSCOE BLVD FL 2
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-1219
Practice Address - Country:US
Practice Address - Phone:818-901-4830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109077106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist