Healthcare Provider Details

I. General information

NPI: 1023184579
Provider Name (Legal Business Name): SUSAN LEA LUALLEN MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 RIO LINDO AVENUE SUITE 204
CHICO CA
95926
US

IV. Provider business mailing address

2602 CHICO RIVER ROAD
CHICO CA
95928
US

V. Phone/Fax

Practice location:
  • Phone: 530-879-3950
  • Fax: 530-879-3949
Mailing address:
  • Phone: 530-343-8886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number42259
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: