Provider Demographics
NPI:1285301176
Name:TRIDLE, SUSAN RENEE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENEE
Last Name:TRIDLE
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 1:1844 310TH ST
Mailing Address - Street 2:
Mailing Address - City:ORIENT
Mailing Address - State:IA
Mailing Address - Zip Code:50858-8017
Mailing Address - Country:US
Mailing Address - Phone:641-745-0002
Mailing Address - Fax:
Practice Address - Street 1:3805 LOWER BEAVER RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-4708
Practice Address - Country:US
Practice Address - Phone:515-279-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)