MEDICARE: SUSAN M. LOVE MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFT 7779	CA

General Provider Information

NPI Number	:	1366613853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M. LOVE MFT

Provider Business Mailing Address
First Line	:	405 W MAIN ST
Second Line	:
City	:	GRASS VALLEY
State	:	CA
Zip	:	95945-6403
Country	:	US
Telephone Number	:	530-273-7002
Fax Number	:	530-478-5703

Provider Business Practice Location Address
First Line	:	405 W MAIN ST
Second Line	:
City	:	GRASS VALLEY
State	:	CA
Zip	:	95945-6403
Country	:	US
Telephone Number	:	530-273-7002
Fax Number	:	530-478-5703

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	03/12/2008

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