Provider Demographics
NPI:1750788857
Name:WILSON MAYO, SUSAN J (CADCII)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:J
Last Name:WILSON MAYO
Suffix:
Gender:F
Credentials:CADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32274 SCAP-VERN HWY
Mailing Address - Street 2:
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-2317
Mailing Address - Country:US
Mailing Address - Phone:503-987-1439
Mailing Address - Fax:
Practice Address - Street 1:32274 SCAP-VERM HWY
Practice Address - Street 2:
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-2317
Practice Address - Country:US
Practice Address - Phone:503-987-1439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR98-07-43101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)