Provider Demographics
NPI:1285665232
Name:STOCKTON, SUSAN R (CNMT, LMT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:STOCKTON
Suffix:
Gender:F
Credentials:CNMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 RED HORSE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-3125
Mailing Address - Country:US
Mailing Address - Phone:208-407-7244
Mailing Address - Fax:
Practice Address - Street 1:575 E PARKCENTER BLVD STE 190
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6773
Practice Address - Country:US
Practice Address - Phone:208-407-7244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2024-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA44626225700000X
TXMT040994225700000X
IDMASG-218225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist