Provider Demographics
NPI:1619017142
Name:DAWDY, SUSAN H (1041C0700X)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:DAWDY
Suffix:
Gender:F
Credentials:1041C0700X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4241 SE 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3927
Mailing Address - Country:US
Mailing Address - Phone:413-281-5130
Mailing Address - Fax:
Practice Address - Street 1:4241 SE 15TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3927
Practice Address - Country:US
Practice Address - Phone:413-281-5130
Practice Address - Fax:413-961-2574
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL70141041C0700X
MA113862251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health