Provider Demographics
NPI:1487982419
Name:SHADDICK, SUSAN M (MA, MFT)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:SHADDICK
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35501 S HIGHWAY 1 UNIT 23
Mailing Address - Street 2:
Mailing Address - City:GUALALA
Mailing Address - State:CA
Mailing Address - Zip Code:95445-9545
Mailing Address - Country:US
Mailing Address - Phone:707-889-3442
Mailing Address - Fax:707-884-1930
Practice Address - Street 1:621 CHERRY ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4202
Practice Address - Country:US
Practice Address - Phone:707-884-9706
Practice Address - Fax:707-884-1930
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37864106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist