Provider Demographics
NPI:1316268832
Name:WILLIS, SUSAN DIANE (MA)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:DIANE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 RANCHO WAY
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-4533
Mailing Address - Country:US
Mailing Address - Phone:916-921-0828
Mailing Address - Fax:916-921-0333
Practice Address - Street 1:3951 PERFORMANCE DR
Practice Address - Street 2:SUITE #G
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3264
Practice Address - Country:US
Practice Address - Phone:916-921-0828
Practice Address - Fax:916-921-0333
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45707106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist