1679789879 NPI number — MS. SUZETTE S. DIERKES L.M.F.T.

Table of content: (NPI 1952965949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679789879 NPI number — MS. SUZETTE S. DIERKES L.M.F.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIERKES
Provider First Name:
SUZETTE
Provider Middle Name:
S.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.M.F.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679789879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 74
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLISTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95024-0074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-524-2371
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
449 SAN BENITO ST
Provider Second Line Business Practice Location Address:
SUITE 27
Provider Business Practice Location Address City Name:
HOLLISTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95023-3946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-524-2371
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC 45321 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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