Provider Demographics
NPI:1487081394
Name:FORDICE, SUSAN D
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:FORDICE
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 1:2013 SW OLSON
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801
Mailing Address - Country:US
Mailing Address - Phone:541-240-1446
Mailing Address - Fax:
Practice Address - Street 1:2013 SW OLSON AVE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-4421
Practice Address - Country:US
Practice Address - Phone:541-240-1446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness