Provider Demographics
NPI:1124649660
Name:NIELSEN, SUZANNE MARIE
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARIE
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 MAJOR AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2342
Mailing Address - Country:US
Mailing Address - Phone:307-856-6587
Mailing Address - Fax:
Practice Address - Street 1:770 E 11TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3746
Practice Address - Country:US
Practice Address - Phone:458-205-7085
Practice Address - Fax:458-205-6924
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
OR23QMHAR3551101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker