Provider Demographics
NPI:1073695508
Name:BAMFORD, SUSAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:BAMFORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7845 BURTON PL SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-9065
Mailing Address - Country:US
Mailing Address - Phone:503-581-7600
Mailing Address - Fax:503-581-6995
Practice Address - Street 1:1845 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5203
Practice Address - Country:US
Practice Address - Phone:503-581-7600
Practice Address - Fax:503-581-6995
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR742101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR114454Medicare ID - Type Unspecified