Provider Demographics
NPI:1245562172
Name:BROADHURST, SUSAN (OT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BROADHURST
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 MARTIN LUTHER KING JR WAY S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-2182
Mailing Address - Country:US
Mailing Address - Phone:206-325-5325
Mailing Address - Fax:206-325-5326
Practice Address - Street 1:4515 MARTIN LUTHER KING JR WAY S
Practice Address - Street 2:SUITE 100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-2182
Practice Address - Country:US
Practice Address - Phone:206-325-5325
Practice Address - Fax:206-325-5326
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT0001772225X00000X
OR984994225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOT00001772OtherWASHINGTON DEPARTMENT OF HEALTH
OR984994OtherOREGON DEPARTMENT OF HEALTH