Provider Demographics
NPI:1780036004
Name:SHEPHERD, SUZANNA
Entity Type:Individual
Prefix:
First Name:SUZANNA
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22026 20TH AVE SE STE 101
Mailing Address - Street 2:CANYON PARK TREATMENT SOLUTIONS
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-4449
Mailing Address - Country:US
Mailing Address - Phone:425-672-7293
Mailing Address - Fax:425-329-4640
Practice Address - Street 1:22026 20TH AVE SE STE 101
Practice Address - Street 2:CANYON PARK TREATMENT SOLUTIONS
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98021-4449
Practice Address - Country:US
Practice Address - Phone:425-672-7293
Practice Address - Fax:425-329-4640
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60656742390200000X
WACO60656742101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACO60656742Medicaid