Provider Demographics
NPI:1902129620
Name:SUSAN COOLBAUGH, INC
Entity Type:Organization
Organization Name:SUSAN COOLBAUGH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:COOLBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:253-983-8507
Mailing Address - Street 1:6212 75TH ST W
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-8368
Mailing Address - Country:US
Mailing Address - Phone:253-983-8507
Mailing Address - Fax:253-983-8576
Practice Address - Street 1:6212 75TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-8368
Practice Address - Country:US
Practice Address - Phone:253-983-8507
Practice Address - Fax:253-983-8576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004202261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB29819Medicare UPIN