Provider Demographics
NPI:1366757353
Name:LOUIS, SUSAN R (LMP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:LOUIS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 674
Mailing Address - Street 2:
Mailing Address - City:RAINIER
Mailing Address - State:WA
Mailing Address - Zip Code:98576-0674
Mailing Address - Country:US
Mailing Address - Phone:360-339-2404
Mailing Address - Fax:
Practice Address - Street 1:14510 164 SE
Practice Address - Street 2:
Practice Address - City:RAINIER
Practice Address - State:WA
Practice Address - Zip Code:98576
Practice Address - Country:US
Practice Address - Phone:360-339-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009253225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist