Provider Demographics
NPI:1366988032
Name:BONNEN, SUZANNE (LMT 16652)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:BONNEN
Suffix:
Gender:F
Credentials:LMT 16652
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 NW MENLO DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1948
Mailing Address - Country:US
Mailing Address - Phone:541-602-9577
Mailing Address - Fax:
Practice Address - Street 1:564 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4439
Practice Address - Country:US
Practice Address - Phone:541-602-9577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16652225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR16652OtherOREGON BOARD OF MASSAGE