=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326379876
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN C. MACKSEY M.A. M.F.T. INTERN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2010
-----------------------------------------------------
Last Update Date | 02/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1533 EUCLID ST
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-3306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-451-9747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1533 EUCLID ST
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-3306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-451-9747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 61387
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------