Provider Demographics
NPI:1528198264
Name:HENRICKSEN, SUSAN JOLINE (LMP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JOLINE
Last Name:HENRICKSEN
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 1:6618 SO L ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408
Mailing Address - Country:US
Mailing Address - Phone:253-471-2937
Mailing Address - Fax:253-475-8827
Practice Address - Street 1:6618 SO L ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408
Practice Address - Country:US
Practice Address - Phone:253-471-2937
Practice Address - Fax:253-475-8827
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013316225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist