Provider Demographics
NPI:1568730620
Name:TOMASELLI, SUSAN MARIE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:TOMASELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 OLD BEAR TRL
Mailing Address - Street 2:
Mailing Address - City:IVANHOE
Mailing Address - State:VA
Mailing Address - Zip Code:24350-3707
Mailing Address - Country:US
Mailing Address - Phone:276-228-4343
Mailing Address - Fax:276-228-4343
Practice Address - Street 1:1175 WEST MAIN ST.
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2157
Practice Address - Country:US
Practice Address - Phone:276-228-4343
Practice Address - Fax:276-228-4343
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019000550225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist