Provider Demographics
NPI:1083749394
Name:SINNOTT, SUSAN K (MS, LMFT, LD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:SINNOTT
Suffix:
Gender:F
Credentials:MS, LMFT, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:
Practice Address - Street 1:790 E 5TH ST
Practice Address - Street 2:
Practice Address - City:COQUILLE
Practice Address - State:OR
Practice Address - Zip Code:97423-1755
Practice Address - Country:US
Practice Address - Phone:541-396-3111
Practice Address - Fax:541-396-5222
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0517106H00000X
OR90133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407812365OtherGROUP NPI NUMBER
ORT0517OtherLICENSE-MARRIAGE & FAMILY THERAPIST
OR930635514OtherGROUP TAX ID FOR BILLING
ORR0000WFBTVOtherGROUP MEDICARE PIN NUMBER
OR90OtherLICENSE-DIETITIAN
ORR131478Medicare PIN
OR0577260001Medicare NSC