Healthcare Provider Details

I. General information

NPI: 1235366790
Provider Name (Legal Business Name): SUSAN ANN GEBHARDT LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12503 SE MILL PLAIN BLVD SUITE 119A
VANCOUVER WA
98684
US

IV. Provider business mailing address

12503 SE MILL PLAIN BLVD SUITE 119A
VANCOUVER WA
98684
US

V. Phone/Fax

Practice location:
  • Phone: 360-718-7747
  • Fax: 360-852-8041
Mailing address:
  • Phone: 360-718-7747
  • Fax: 360-852-8041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH 00011047
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: