Healthcare Provider Details

I. General information

NPI: 1124649660
Provider Name (Legal Business Name): SUZANNE MARIE NIELSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 E 11TH AVE
EUGENE OR
97401-3746
US

IV. Provider business mailing address

1110 MAJOR AVE
RIVERTON WY
82501-2342
US

V. Phone/Fax

Practice location:
  • Phone: 458-205-7085
  • Fax: 458-205-6924
Mailing address:
  • Phone: 307-856-6587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23QMHAR3551
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: