Basic Information
| Provider Information | |||||||||
| NPI: | 1679778914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | K | ||||||||
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| NameSuffix: | IV | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21865 BEAR CREEK RD | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977019660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413188082 | ||||||||
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| Practice Location | |||||||||
| Address1: | 63360 NW BRITTA ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977019475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413184845 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 07/20/2007 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.