Provider Demographics
NPI:1598163768
Name:MARSHALL, SUSAN (GCFP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:GCFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3059 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3272
Mailing Address - Country:US
Mailing Address - Phone:503-313-9813
Mailing Address - Fax:
Practice Address - Street 1:3026 NE OREGON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2450
Practice Address - Country:US
Practice Address - Phone:503-313-9813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4526174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator