1619098167 NPI number — MRS. SUSAN LYNN DIMOCK LCSW

Table of content: AGNES EDITH OWUOR OBITA-OUNDA M.D (NPI 1639590227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619098167 NPI number — MRS. SUSAN LYNN DIMOCK LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIMOCK
Provider First Name:
SUSAN
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
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:
1619098167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 252
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANDON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97411-0252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-347-7090
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1212 ALABAMA ST
Provider Second Line Business Practice Location Address:
SUITE 27
Provider Business Practice Location Address City Name:
BANDON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-347-7090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2007

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: 1041C0700X , with the licence number:  L3672 , 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: J015501 . This is a "PACIFIC SOURCE ID NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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