Provider Demographics
NPI:1184113904
Name:LESTER, SUSAN ELAINE (LMT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELAINE
Last Name:LESTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 SW MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6690
Mailing Address - Country:US
Mailing Address - Phone:503-539-6989
Mailing Address - Fax:
Practice Address - Street 1:12405 SW MAIN ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6190
Practice Address - Country:US
Practice Address - Phone:503-620-4880
Practice Address - Fax:503-620-4886
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3636225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist