Provider Demographics
NPI:1245561570
Name:VITTNER, SUSAN (MT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:VITTNER
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 NORTH ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2777
Mailing Address - Country:US
Mailing Address - Phone:210-559-6419
Mailing Address - Fax:
Practice Address - Street 1:67 NORTH ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2777
Practice Address - Country:US
Practice Address - Phone:210-559-6419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4173225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist