Provider Demographics
NPI:1700638772
Name:SYWULKA, SUSAN ANN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:SYWULKA
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 1:6130 AQUARIUS AVE
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9243
Mailing Address - Country:US
Mailing Address - Phone:360-684-4566
Mailing Address - Fax:
Practice Address - Street 1:6130 AQUARIUS AVE
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-9243
Practice Address - Country:US
Practice Address - Phone:360-648-4566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA61528423103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst