Provider Demographics
NPI:1740893353
Name:GAMBOA, SUSIE LILLIANA (MS, AMFT)
Entity type:Individual
Prefix:
First Name:SUSIE
Middle Name:LILLIANA
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:MS, AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 461
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-0461
Mailing Address - Country:US
Mailing Address - Phone:951-373-6961
Mailing Address - Fax:
Practice Address - Street 1:3636 CAMINO DEL RIO N STE 150
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1709
Practice Address - Country:US
Practice Address - Phone:951-373-6961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119718171M00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator