Provider Demographics
NPI:1598381006
Name:PREST, SUSAN (LMT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PREST
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 1:2450 HOSPITAL DR STE 160
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2381
Mailing Address - Country:US
Mailing Address - Phone:318-210-9770
Mailing Address - Fax:
Practice Address - Street 1:2450 HOSPITAL DR STE 160
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2381
Practice Address - Country:US
Practice Address - Phone:318-210-9770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3234225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist