Provider Demographics
NPI:1770970444
Name:SUYAT, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SUYAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 BASELINE RD
Mailing Address - Street 2:BOX 400
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2353
Mailing Address - Country:US
Mailing Address - Phone:909-883-2986
Mailing Address - Fax:
Practice Address - Street 1:233 BASELINE RD
Practice Address - Street 2:BOX 400
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2353
Practice Address - Country:US
Practice Address - Phone:909-883-2986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65424104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7565AOtherOUTPATIENT MENTAL HEALTH