Provider Demographics
NPI:1619098167
Name:DIMOCK, SUSAN LYNN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LYNN
Last Name:DIMOCK
Suffix:
Gender:F
Credentials:LCSW
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 252
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-0252
Mailing Address - Country:US
Mailing Address - Phone:541-347-7090
Mailing Address - Fax:
Practice Address - Street 1:1212 ALABAMA ST
Practice Address - Street 2:SUITE 27
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411
Practice Address - Country:US
Practice Address - Phone:541-347-7090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL36721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORJ015501OtherPACIFIC SOURCE ID NUMBER
ORJ015501OtherPACIFIC SOURCE ID NUMBER