Provider Demographics
NPI:1417195660
Name:PEARSON, SUSAN L (LMP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:PEARSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 123
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98235-0123
Mailing Address - Country:US
Mailing Address - Phone:360-856-1528
Mailing Address - Fax:
Practice Address - Street 1:12263 N. MILL STREET
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:WA
Practice Address - Zip Code:98284
Practice Address - Country:US
Practice Address - Phone:360-856-1528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA000-25403225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist