Provider Demographics
NPI:1487880050
Name:DAWSON, M SUSAN (PMHNP)
Entity type:Individual
Prefix:
First Name:M
Middle Name:SUSAN
Last Name:DAWSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:DAWSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PMHNP
Mailing Address - Street 1:2650 OLIVE STREET
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103
Mailing Address - Country:US
Mailing Address - Phone:314-371-6500
Mailing Address - Fax:314-371-6508
Practice Address - Street 1:2650 OLIVE STREET
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103
Practice Address - Country:US
Practice Address - Phone:314-371-6500
Practice Address - Fax:314-371-6508
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO065344163WP0809X, 363LP0808X
IAT114819163WP0809X
IL209.005621163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO147370019Medicare PIN