Basic Information
| Provider Information | |||||||||
| NPI: | 1104006725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE TARR | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.S.W., CADC 1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 KAEN RD | ||||||||
| Address2: | 367 | ||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454035 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1002 LIBRARY CT | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036558264 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2007 | ||||||||
| LastUpdateDate: | 07/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | L5953 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.