Provider Demographics
NPI:1578723912
Name:OLDLAND, SUSAN M (LMT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:OLDLAND
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86451 FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-9642
Mailing Address - Country:US
Mailing Address - Phone:541-744-8944
Mailing Address - Fax:
Practice Address - Street 1:1755 COBURG RD
Practice Address - Street 2:BLDG 4, STE 2
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4982
Practice Address - Country:US
Practice Address - Phone:541-684-3988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14948171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR14948OtherMASSAGE LICENSE