Provider Demographics
NPI:1558117531
Name:ELLIOTT, SUSAN LIANNE (APCC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LIANNE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LIANNE
Other - Last Name:KENLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APCC
Mailing Address - Street 1:41661 ENTERPRISE CIR N STE 111
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5629
Mailing Address - Country:US
Mailing Address - Phone:909-289-0139
Mailing Address - Fax:
Practice Address - Street 1:41661 ENTERPRISE CIR N STE 111
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5629
Practice Address - Country:US
Practice Address - Phone:951-319-9434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15487101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional