Healthcare Provider Details

I. General information

NPI: 1740378850
Provider Name (Legal Business Name): SUSAN OWRE GELBERG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN LAURA OWRE

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 STATE STREET OREGON STATE PENITENTIARY
SALEM OR
97310
US

IV. Provider business mailing address

2553 NW MICHELLE DRIVE
CORVALLIS OR
97330
US

V. Phone/Fax

Practice location:
  • Phone: 541-745-5549
  • Fax:
Mailing address:
  • Phone: 541-745-5549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1677
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071004327
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: