Provider Demographics
NPI:1073989232
Name:ENERSON, SUSAN R (OT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:ENERSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:RAE
Other - Last Name:HOMGREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:2100 E CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-214-7430
Mailing Address - Fax:928-214-6022
Practice Address - Street 1:2100 E CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-214-7430
Practice Address - Fax:928-214-6022
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0121225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist