Healthcare Provider Details

I. General information

NPI: 1144265596
Provider Name (Legal Business Name): SUSAN MARIE SOUTH PSY D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 WINTER ST NE
SALEM OR
97301
US

IV. Provider business mailing address

PO BOX 96103
PORTLAND OR
97296
US

V. Phone/Fax

Practice location:
  • Phone: 541-730-5669
  • Fax: 800-764-6136
Mailing address:
  • Phone: 541-730-5669
  • Fax: 800-764-6136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1457
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: