1104115849 NPI number — SUSAN ANN PONTON LCSW

Table of content: SUSAN ANN PONTON LCSW (NPI 1104115849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104115849 NPI number — SUSAN ANN PONTON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PONTON
Provider First Name:
SUSAN
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1104115849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1014 MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-695-1014
Provider Business Mailing Address Fax Number:
360-750-1374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10130 NE SKIDMORE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97220-3570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-257-3787
Provider Business Practice Location Address Fax Number:
971-279-4634
Provider Enumeration Date:
04/04/2011

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: 1041C0700X , with the licence number:  L8443 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: L8443 . This is a "LICENSED CLINICAL SOCIAL WORKER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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