Provider Demographics
NPI:1154477420
Name:HEATH, SUSAN ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANN
Last Name:HEATH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:KISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSW
Mailing Address - Street 1:1247 HEATHER LN SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1523
Mailing Address - Country:US
Mailing Address - Phone:503-999-2748
Mailing Address - Fax:503-585-3261
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:503-315-8575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0610OtherLCSW