Provider Demographics
NPI:1740378850
Name:GELBERG, SUSAN OWRE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:OWRE
Last Name:GELBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LAURA
Other - Last Name:OWRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2553 NW MICHELLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330
Mailing Address - Country:US
Mailing Address - Phone:541-745-5549
Mailing Address - Fax:
Practice Address - Street 1:2605 STATE STREET
Practice Address - Street 2:OREGON STATE PENITENTIARY
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97310
Practice Address - Country:US
Practice Address - Phone:541-745-5549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1677103T00000X
IL071004327103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR136013Medicare PIN