Provider Demographics
NPI:1669207833
Name:FAIX, SUSAN MARIE (MFC #44579)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:FAIX
Suffix:
Gender:F
Credentials:MFC #44579
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 EFFEY ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2632
Mailing Address - Country:US
Mailing Address - Phone:831-239-4695
Mailing Address - Fax:
Practice Address - Street 1:429 EFFEY ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2632
Practice Address - Country:US
Practice Address - Phone:831-239-4695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44579106H00000X
CA45579106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist