=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790829190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN ELIZABETH LENNEN MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2007
-----------------------------------------------------
Last Update Date | 09/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2727 CAMINO DEL RIO S STE 150
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-3750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-208-1575
-----------------------------------------------------
Fax | 619-677-3984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5198 EDGEWORTH RD
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92109-1429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-208-1575
-----------------------------------------------------
Fax | 619-677-3984
-----------------------------------------------------
=====================================================
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 | MFC18989
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------