Provider Demographics
NPI:1144265596
Name:SOUTH, SUSAN MARIE (PSY D)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:SOUTH
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 96103
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97296
Mailing Address - Country:US
Mailing Address - Phone:541-730-5669
Mailing Address - Fax:800-764-6136
Practice Address - Street 1:627 WINTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:541-730-5669
Practice Address - Fax:800-764-6136
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR14572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP68960Medicare UPIN