Provider Demographics
NPI:1144797457
Name:SURDEZ, SUSAN ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ALEXANDRIA
Last Name:SURDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 110774
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98411-0774
Mailing Address - Country:US
Mailing Address - Phone:206-880-1053
Mailing Address - Fax:
Practice Address - Street 1:325 E PIONEER
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3265
Practice Address - Country:US
Practice Address - Phone:253-697-8400
Practice Address - Fax:253-697-3730
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61202927101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health