Healthcare Provider Details

I. General information

NPI: 1679218887
Provider Name (Legal Business Name): SUSANNE EISENHART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17995 OUTER HWY 18
APPLE VALLEY CA
92307-2190
US

IV. Provider business mailing address

12421 HESPERIA RD STE 2
VICTORVILLE CA
92395-7704
US

V. Phone/Fax

Practice location:
  • Phone: 760-243-5417
  • Fax:
Mailing address:
  • Phone: 760-243-5417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT164708
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: