Provider Demographics
NPI:1215063755
Name:SEIDMAN, SUSAN CAMILLE (MFT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAMILLE
Last Name:SEIDMAN
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 1:1128 E 6TH ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-5706
Mailing Address - Country:US
Mailing Address - Phone:951-734-8831
Mailing Address - Fax:951-734-8518
Practice Address - Street 1:1128 E 6TH ST
Practice Address - Street 2:SUITE 8
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-5706
Practice Address - Country:US
Practice Address - Phone:951-734-8831
Practice Address - Fax:951-734-8518
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34822106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist