Healthcare Provider Details

I. General information

NPI: 1649382524
Provider Name (Legal Business Name): SUZANE E BAILEY LCSW, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 TAMERA DR
KLAMATH FALLS OR
97603-4179
US

IV. Provider business mailing address

1535 TAMERA DR
KLAMATH FALLS OR
97603-4179
US

V. Phone/Fax

Practice location:
  • Phone: 541-884-2911
  • Fax: 541-884-7987
Mailing address:
  • Phone: 541-884-2911
  • Fax: 541-884-7987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1125
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier0000931187926
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerTRICARE
# 2
Identifier62-74831
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerUBH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: