Provider Demographics
NPI:1902923857
Name:ROSENTHALL, SUSAN A
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:ROSENTHALL
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 1:1020 SW TAYLOR ST
Mailing Address - Street 2:SUITE 755
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST
Practice Address - Street 2:SUITE 755
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2543
Practice Address - Country:US
Practice Address - Phone:503-223-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR05631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR053657Medicaid
109434Medicare ID - Type Unspecified