Provider Demographics
NPI:1669579355
Name:BOYDSTUN, SUSAN GILLETT (LMFT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:GILLETT
Last Name:BOYDSTUN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 E CAMBRIDGE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-6203
Mailing Address - Country:US
Mailing Address - Phone:559-229-3787
Mailing Address - Fax:
Practice Address - Street 1:1500 W SHAW SUITE 301
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3501
Practice Address - Country:US
Practice Address - Phone:559-903-7052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMU18212106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist