Healthcare Provider Details

I. General information

NPI: 1548401268
Provider Name (Legal Business Name): SUSANA E MARCO MFTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 LONG BEACH BLVD SUITE 700
LONG BEACH CA
90807-2011
US

IV. Provider business mailing address

1304 W 2ND ST APT. #130
LOS ANGELES CA
90026-7003
US

V. Phone/Fax

Practice location:
  • Phone: 310-783-4677
  • Fax:
Mailing address:
  • Phone: 323-533-5620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: