Provider Demographics
NPI:1730856394
Name:DORN, SUSAN M (MFTA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:DORN
Suffix:
Gender:F
Credentials:MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6825 31ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-7244
Mailing Address - Country:US
Mailing Address - Phone:425-517-9523
Mailing Address - Fax:
Practice Address - Street 1:6825 31ST AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-7244
Practice Address - Country:US
Practice Address - Phone:425-517-9523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61166216106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61166216OtherWA STATE DEPARTMENT OF HEALTH