Healthcare Provider Details

I. General information

NPI: 1417464967
Provider Name (Legal Business Name): SUSAN MICHELLE MANNOS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6591 SUTTON ST
WESTMINSTER CA
92683-2116
US

IV. Provider business mailing address

25622 ADRIANA ST
MISSION VIEJO CA
92691-3824
US

V. Phone/Fax

Practice location:
  • Phone: 657-340-1005
  • Fax:
Mailing address:
  • Phone: 949-338-1335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number300049AP
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF75648
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT110222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: