Basic Information
| Provider Information | |||||||||
| NPI: | 1083749394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SINNOTT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MS, LMFT, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974200000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
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| Practice Location | |||||||||
| Address1: | 790 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | COQUILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974231755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413963111 | ||||||||
| FaxNumber: | 5413965222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 04/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | T0517 | OR | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 133V00000X | 90 | OR | N | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1407812365 | 01 | OR | GROUP NPI NUMBER | OTHER | T0517 | 01 | OR | LICENSE-MARRIAGE & FAMILY THERAPIST | OTHER | 930635514 | 01 | OR | GROUP TAX ID FOR BILLING | OTHER | R0000WFBTV | 01 | OR | GROUP MEDICARE PIN NUMBER | OTHER | 90 | 01 | OR | LICENSE-DIETITIAN | OTHER |