Provider Demographics
NPI:1396214185
Name:NORMAN, SUZANNE ELIZABETH (CP60981123)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:NORMAN
Suffix:
Gender:F
Credentials:CP60981123
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-4817
Mailing Address - Country:US
Mailing Address - Phone:360-748-4339
Mailing Address - Fax:
Practice Address - Street 1:135 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-4817
Practice Address - Country:US
Practice Address - Phone:360-748-4339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO608113943101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2077844Medicaid