Provider Demographics
NPI:1295289981
Name:MCDONALD, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:H
Other - Last Name:MOTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CST/CSFA
Mailing Address - Street 1:1169 N BURLESON BLVD # 107-233
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7011
Mailing Address - Country:US
Mailing Address - Phone:817-269-1472
Mailing Address - Fax:817-531-2939
Practice Address - Street 1:1400 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-269-1472
Practice Address - Fax:817-531-2939
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX88493174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208094511OtherFEDERAL TAX ID