Provider Demographics
NPI:1245590686
Name:BIRNBAUM, SUSAN KATHLEEN (MPT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KATHLEEN
Last Name:BIRNBAUM
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4378 W QUAIL POINT CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3844
Mailing Address - Country:US
Mailing Address - Phone:208-424-0324
Mailing Address - Fax:
Practice Address - Street 1:600 N ROBBINS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4565
Practice Address - Country:US
Practice Address - Phone:208-489-4640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-19
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist