Provider Demographics
NPI:1275983769
Name:NEWSOM, SUSSETTE HIERS
Entity Type:Individual
Prefix:
First Name:SUSSETTE
Middle Name:HIERS
Last Name:NEWSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2173 S GEKELER LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4337
Mailing Address - Country:US
Mailing Address - Phone:208-333-8751
Mailing Address - Fax:
Practice Address - Street 1:2173 S GEKELER LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-4337
Practice Address - Country:US
Practice Address - Phone:208-333-8751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID561225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist