Provider Demographics
NPI:1841509346
Name:SUSMAN, MELISSA SUE
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:SUE
Last Name:SUSMAN
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 1:508 BOCCACCIO AVE # B
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-4807
Mailing Address - Country:US
Mailing Address - Phone:310-291-1448
Mailing Address - Fax:
Practice Address - Street 1:11340 W OLYMPIC BLVD STE 266
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1608
Practice Address - Country:US
Practice Address - Phone:310-291-1448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86889106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist