Provider Demographics
NPI:1992227573
Name:IBRAHIM, SUSIE MARIA (MFTI)
Entity type:Individual
Prefix:MRS
First Name:SUSIE
Middle Name:MARIA
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIA
Other - Last Name:ALEXANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17772 IRVINE BLVD SUITE 102-1
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780
Mailing Address - Country:US
Mailing Address - Phone:657-333-6144
Mailing Address - Fax:
Practice Address - Street 1:17772 IRVINE BLVD
Practice Address - Street 2:SUITE 102-1
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780
Practice Address - Country:US
Practice Address - Phone:657-333-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96254106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty