Provider Demographics
NPI:1720062490
Name:FINE, SUSANNE (PSYD, RN, CNS)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:FINE
Suffix:
Gender:F
Credentials:PSYD, RN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7404
Mailing Address - Country:US
Mailing Address - Phone:541-245-1123
Mailing Address - Fax:
Practice Address - Street 1:1117 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7404
Practice Address - Country:US
Practice Address - Phone:541-245-1123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1546103TC0700X
OR200870007CNS-PP364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR#1546OtherPSYCHOLOGIST
OR200870007CNS-PPOtherCLINICAL NURSE PRACTTIONER/ARNP
OR203321773OtherEIN#