Provider Demographics
NPI:1982935292
Name:SAN TARA, SUSAN THOMPSON (MFT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:THOMPSON
Last Name:SAN TARA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:THMPSON
Other - Last Name:SAN ROMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT
Mailing Address - Street 1:2915 MARTIN LUTHER KING JR. WAY
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703
Mailing Address - Country:US
Mailing Address - Phone:510-452-6156
Mailing Address - Fax:510-548-8998
Practice Address - Street 1:2915 MARTIN LUTHER KING JR. WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703
Practice Address - Country:US
Practice Address - Phone:510-452-6156
Practice Address - Fax:510-548-8998
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43157106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist