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General NPI Number Information
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NPI Number | 1346405693
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Entity Type | Individual
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Provider Name | SUZANNE TAVOULARIS BENJESTORF MFT, PHD
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Gender | Female
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Dates
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Enumeration Date | 07/25/2008
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Last Update Date | 09/05/2023
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Provider Practice Location Address
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Address Line | 3937 9TH AVE
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City | SAN DIEGO
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State | CA
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Zip | 92103-3210
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Country | US
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Telephone | 619-298-2401
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 83912
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City | SAN DIEGO
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State | CA
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Zip | 92138-3912
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Country | US
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Telephone | 858-717-4224
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY20520
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MFT31894
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License Number State | CA
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