Provider Demographics
NPI:1083656680
Name:WEST, SUSAN IRENE (OT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:IRENE
Last Name:WEST
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:IRENE
Other - Last Name:FULTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:407 BLACK HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301-3243
Mailing Address - Country:US
Mailing Address - Phone:308-762-6564
Mailing Address - Fax:308-762-3747
Practice Address - Street 1:407 BLACK HILLS AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-3243
Practice Address - Country:US
Practice Address - Phone:308-762-6564
Practice Address - Fax:308-762-3747
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE689225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025312800Medicaid
NE69854OtherBCBS OF NE
NE10025312800Medicaid
670002032Medicare ID - Type UnspecifiedRR MEDICARE