1861553075 NPI number — DR. SUZANNE MERADITH CLANTON PSY.D.

Table of content: DR. SUZANNE MERADITH CLANTON PSY.D. (NPI 1861553075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861553075 NPI number — DR. SUZANNE MERADITH CLANTON PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLANTON
Provider First Name:
SUZANNE
Provider Middle Name:
MERADITH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
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:
1861553075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 891
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97075-0891
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-660-3106
Provider Business Mailing Address Fax Number:
503-747-7159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 E EVERGREEN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661-4289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-660-3106
Provider Business Practice Location Address Fax Number:
503-747-7159
Provider Enumeration Date:
12/12/2006

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: 103TC0700X , with the licence number:  PY00003853 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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