Provider Demographics
NPI:1710097746
Name:TIDDY, SUZANNE GAIL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:GAIL
Last Name:TIDDY
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 1:712 SW MILLER CT
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-9396
Mailing Address - Country:US
Mailing Address - Phone:503-491-0399
Mailing Address - Fax:503-667-2893
Practice Address - Street 1:10373 NE HANCOCK ST
Practice Address - Street 2:SUITE 220
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3873
Practice Address - Country:US
Practice Address - Phone:503-491-0399
Practice Address - Fax:503-667-2893
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL0008301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical