Provider Demographics
NPI:1447508841
Name:PERRY, SUSAN BURDICK
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:BURDICK
Last Name:PERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6305 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-2346
Mailing Address - Country:US
Mailing Address - Phone:818-908-4999
Mailing Address - Fax:818-908-0123
Practice Address - Street 1:6305 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-2346
Practice Address - Country:US
Practice Address - Phone:818-908-4999
Practice Address - Fax:818-908-0123
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF71370106H00000X
225400000X
CALMFT110701106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner