Healthcare Provider Details

I. General information

NPI: 1720853039
Provider Name (Legal Business Name): HEATHER SUSAN PERSONS AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2023
Last Update Date: 11/18/2023
Certification Date: 11/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23228 MADERO
MISSION VIEJO CA
92691-2706
US

IV. Provider business mailing address

23228 MADERO
MISSION VIEJO CA
92691-2706
US

V. Phone/Fax

Practice location:
  • Phone: 949-454-3940
  • Fax: 949-770-1953
Mailing address:
  • Phone: 949-454-3940
  • Fax: 949-770-1953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number138042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: