Provider Demographics
NPI:1770955528
Name:HERTEL, SUSAN LYNN (BA, ACCBC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LYNN
Last Name:HERTEL
Suffix:
Gender:F
Credentials:BA, ACCBC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 ARROWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407
Mailing Address - Country:US
Mailing Address - Phone:707-284-2950
Mailing Address - Fax:707-284-2955
Practice Address - Street 1:440 ARROWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407
Practice Address - Country:US
Practice Address - Phone:707-284-2950
Practice Address - Fax:707-284-2955
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAH0902181354101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)