Provider Demographics
NPI:1689611154
Name:STORMER, SUSAN MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:STORMER
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 1:7327 SW BARNES RD # 420
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6119
Mailing Address - Country:US
Mailing Address - Phone:503-902-5000
Mailing Address - Fax:
Practice Address - Street 1:916 SW KING AVE STE 203
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1320
Practice Address - Country:US
Practice Address - Phone:503-902-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31450103TC0700X
WAPY61341034103TC0700X
OR2800103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145683205Medicaid
TX145683206Medicaid
TXP00009482OtherRAILROAD
TXP00009483OtherRAILROAD
TX86814AOtherBCBS
TX86815AOtherBCBS
TX145683206Medicaid