Healthcare Provider Details

I. General information

NPI: 1316093370
Provider Name (Legal Business Name): SUSAN M. THODE M. ED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 GARFIELD ST
ENUMCLAW WA
98022-2217
US

IV. Provider business mailing address

39626 224TH AVE SE
ENUMCLAW WA
98022-8921
US

V. Phone/Fax

Practice location:
  • Phone: 253-839-1697
  • Fax:
Mailing address:
  • Phone: 360-825-0156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

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: