Provider Demographics
NPI:1518196724
Name:AGRICOLA, SUSAN M (MS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:AGRICOLA
Suffix:
Gender:F
Credentials:MS
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 826
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-0826
Mailing Address - Country:US
Mailing Address - Phone:503-612-0449
Mailing Address - Fax:
Practice Address - Street 1:9843 SW ALSEA DR
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9543
Practice Address - Country:US
Practice Address - Phone:503-612-0449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12120237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR159115Medicare UPIN