Provider Demographics
NPI:1750318788
Name:ROSE, SUSAN S (PHD, GCNS-BC, PMHNP)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:S
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHD, GCNS-BC, PMHNP
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 2077
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2077
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:LEGACY SALMON CREEK PROVIDERS
Practice Address - Street 2:2211 NE 139TH STREET
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2742
Practice Address - Country:US
Practice Address - Phone:503-413-8407
Practice Address - Fax:503-413-6951
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200850041NP363LP0808X
OR200470003364SG0600X
WAAP60031978363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8878364OtherMEDICARE