Provider Demographics
NPI:1720527971
Name:SUSAC, MELISSA (MFT)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
Last Name:SUSAC
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 1:2214 CANYON DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-2402
Mailing Address - Country:US
Mailing Address - Phone:858-876-4774
Mailing Address - Fax:
Practice Address - Street 1:1540 SCHRADER BLVD
Practice Address - Street 2:GARDEN SUITE 12
Practice Address - City:HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90028
Practice Address - Country:US
Practice Address - Phone:858-876-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96855106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist