Provider Demographics
NPI:1467413690
Name:LAVALLEE, SUSAN E (DPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:LAVALLEE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:E
Other - Last Name:LAVALLEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:290 BAKER AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2189
Mailing Address - Country:US
Mailing Address - Phone:978-369-0730
Mailing Address - Fax:
Practice Address - Street 1:290 BAKER AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2189
Practice Address - Country:US
Practice Address - Phone:978-369-0730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA13114OtherMA STATE LICENCE
MARE628801Medicare PIN