Provider Demographics
NPI:1366427759
Name:DR. SUSANNE FINE, LLC
Entity type:Organization
Organization Name:DR. SUSANNE FINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NURSE SPECIALIST/ARNP
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:FINE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, RN, CNS
Authorized Official - Phone:541-245-1123
Mailing Address - Street 1:1117 E MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7404
Mailing Address - Country:US
Mailing Address - Phone:541-245-1123
Mailing Address - Fax:541-245-1123
Practice Address - Street 1:1117 E MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7404
Practice Address - Country:US
Practice Address - Phone:541-245-1123
Practice Address - Fax:541-245-1123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-08
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1546103TC0700X
OR200870007CNS-PP364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1546OtherPSYCHOLOGIST