Healthcare Provider Details

I. General information

NPI: 1962718544
Provider Name (Legal Business Name): SUZANNE L. ZAVALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3554 ROUND BARN BLVD
SANTA ROSA CA
95403-0929
US

IV. Provider business mailing address

738 VALLEY CREST DR
VISTA CA
92084-6606
US

V. Phone/Fax

Practice location:
  • Phone: 707-571-3778
  • Fax:
Mailing address:
  • Phone: 831-588-7107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number69092
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: