Healthcare Provider Details

I. General information

NPI: 1740893353
Provider Name (Legal Business Name): SUSIE LILLIANA GAMBOA MS, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N BRAND BLVD STE 170
GLENDALE CA
91203-2304
US

IV. Provider business mailing address

PO BOX 9173
SAN BERNARDINO CA
92427-0173
US

V. Phone/Fax

Practice location:
  • Phone: 909-453-2984
  • Fax:
Mailing address:
  • Phone: 951-373-6961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number158502
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number158502
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: