Provider Demographics
NPI:1629272976
Name:MALLON, SUSAN (QMHA, BA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:MALLON
Suffix:
Gender:F
Credentials:QMHA, BA
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1975 MCPHERSON ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-3482
Mailing Address - Country:US
Mailing Address - Phone:541-756-2020
Mailing Address - Fax:541-756-8982
Practice Address - Street 1:1975 MCPHERSON ST
Practice Address - Street 2:SUITE 2
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-3482
Practice Address - Country:US
Practice Address - Phone:541-756-2020
Practice Address - Fax:541-756-8982
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health