Provider Demographics
NPI:1467608083
Name:MOORE, SUZANNE MICHELLE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MICHELLE
Last Name:MOORE
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 1:830 NE SOUTH SHORE RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-1132
Mailing Address - Country:US
Mailing Address - Phone:503-302-9258
Mailing Address - Fax:
Practice Address - Street 1:722 NE 162ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-5760
Practice Address - Country:US
Practice Address - Phone:503-515-5566
Practice Address - Fax:503-261-0988
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORSM1219104100000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities