Provider Demographics
NPI:1528125531
Name:LILLEDAHL, SUSAN (SUSAN LILLEDAHL MFT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LILLEDAHL
Suffix:
Gender:F
Credentials:SUSAN LILLEDAHL MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 LA GOMA ST
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2110
Mailing Address - Country:US
Mailing Address - Phone:415-381-6453
Mailing Address - Fax:
Practice Address - Street 1:129 LA GOMA ST
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-9494
Practice Address - Country:US
Practice Address - Phone:415-381-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMC34555106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist