Provider Demographics
NPI:1588700280
Name:BERNT, SUSAN M (MSW, LCSW, LICSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:BERNT
Suffix:
Gender:F
Credentials:MSW, LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 462
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-0462
Mailing Address - Country:US
Mailing Address - Phone:503-819-7095
Mailing Address - Fax:503-328-7994
Practice Address - Street 1:2118 19TH ST
Practice Address - Street 2:#19
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068
Practice Address - Country:US
Practice Address - Phone:503-819-7095
Practice Address - Fax:503-328-7994
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR42881041C0700X
WALW600849721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1588700280Medicaid
WA1588700280Medicaid