Provider Demographics
NPI:1548419161
Name:WELLS, SUSAN J (DPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:WELLS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1704
Mailing Address - Country:US
Mailing Address - Phone:503-769-3123
Mailing Address - Fax:503-769-3176
Practice Address - Street 1:601 N 1ST ST
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1704
Practice Address - Country:US
Practice Address - Phone:503-769-3123
Practice Address - Fax:503-769-3176
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist