Provider Demographics
NPI:1154600559
Name:ODEKERKEN, SUSAN GRUSS (MFT)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:GRUSS
Last Name:ODEKERKEN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21137 PLACERITA CANYON RD
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-1922
Mailing Address - Country:US
Mailing Address - Phone:661-857-0953
Mailing Address - Fax:
Practice Address - Street 1:21137 PLACERITA CANYON RD
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-1922
Practice Address - Country:US
Practice Address - Phone:661-857-0953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC18498106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist