Provider Demographics
NPI:1619094570
Name:HORTON, SUSAN WYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:WYNN
Last Name:HORTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 NE CHKALOV DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5054
Mailing Address - Country:US
Mailing Address - Phone:360-921-0745
Mailing Address - Fax:360-260-9777
Practice Address - Street 1:237 NE CHKALOV DR
Practice Address - Street 2:SUITE 110
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5054
Practice Address - Country:US
Practice Address - Phone:360-921-0745
Practice Address - Fax:360-260-9777
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0274103TC0700X
WAPY1226103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005384000OtherREGENCE BLUECROSS BLUESHI