Provider Demographics
NPI:1588228761
Name:GRANADOS, SUSY (MA60876400)
Entity Type:Individual
Prefix:
First Name:SUSY
Middle Name:
Last Name:GRANADOS
Suffix:
Gender:F
Credentials:MA60876400
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11030 EVERGREEN WAY STE A
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-6633
Mailing Address - Country:US
Mailing Address - Phone:425-239-1974
Mailing Address - Fax:
Practice Address - Street 1:610 BEACH AVE STE 1
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4571
Practice Address - Country:US
Practice Address - Phone:425-422-1558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60876400225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist