Provider Demographics
NPI:1164752564
Name:MAMMEN, SUSAN VARGHESE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:VARGHESE
Last Name:MAMMEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:VARGHESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 ODYSSEY
Mailing Address - Street 2:#165
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3186
Mailing Address - Country:US
Mailing Address - Phone:949-727-2192
Mailing Address - Fax:
Practice Address - Street 1:22 ODYSSEY
Practice Address - Street 2:#165
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3186
Practice Address - Country:US
Practice Address - Phone:949-727-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36259225100000X
NY62-027654225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist