Provider Demographics
NPI:1598583999
Name:PRENETA, SUSAN M
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:PRENETA
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 1:7905 N WASHBURNE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7249
Mailing Address - Country:US
Mailing Address - Phone:971-570-3757
Mailing Address - Fax:
Practice Address - Street 1:5847 NE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1079
Practice Address - Country:US
Practice Address - Phone:971-339-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1355552080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities