Provider Demographics
NPI:1205931912
Name:ETHERIDGE, SUZANNE MARIE (MFT)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:MARIE
Last Name:ETHERIDGE
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 1:23272 MILL CREEK DR
Mailing Address - Street 2:#150
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1641
Mailing Address - Country:US
Mailing Address - Phone:949-829-3945
Mailing Address - Fax:714-669-1237
Practice Address - Street 1:23272 MILL CREEK DR
Practice Address - Street 2:#150
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1641
Practice Address - Country:US
Practice Address - Phone:949-829-3945
Practice Address - Fax:714-669-1237
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40453106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist