MEDICARE: SUSSANNE J MARMOL DE MARTIN

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1376775981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSSANNE J MARMOL DE MARTIN

Provider Business Mailing Address
First Line	:	1821 E DYER RD STE 200
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92705-5700
Country	:	US
Telephone Number	:	949-250-0488
Fax Number	:

Provider Business Practice Location Address
First Line	:	19445 W WARREN AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48228-3361
Country	:	US
Telephone Number	:	313-207-0088
Fax Number	:

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

Provider Enumeration Date	:	08/14/2009
Last Update Date	:	07/23/2021

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