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General NPI Number Information
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NPI Number | 1104115849
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Entity Type | Individual
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Provider Name | SUSAN ANN PONTON LCSW
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Gender | Female
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Dates
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Enumeration Date | 04/04/2011
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Last Update Date | 10/29/2019
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Provider Practice Location Address
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Address Line | 10130 NE SKIDMORE ST
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City | PORTLAND
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State | OR
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Zip | 97220-3570
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Country | US
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Telephone | 503-257-3787
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Fax | 971-279-4634
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Provider Business Mailing Address
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Address Line | 1014 MAIN STREET
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City | VANCOUVER
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State | WA
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Zip | 98660
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Country | US
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Telephone | 360-695-1014
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Fax | 360-750-1374
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | L8443
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License Number State | OR
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