MEDICARE: SUSAN M DORN MFTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	61166216	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61166216	OTHER	WA	WA STATE DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1730856394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M DORN MFTA

Provider Business Mailing Address
First Line	:	6825 31ST AVE NE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-7244
Country	:	US
Telephone Number	:	425-517-9523
Fax Number	:

Provider Business Practice Location Address
First Line	:	6825 31ST AVE NE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-7244
Country	:	US
Telephone Number	:	425-517-9523
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2021
Last Update Date	:	08/23/2021

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