Provider Demographics
NPI:1598879488
Name:BRIDZELL, SUSAN LORRAIN (LMP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LORRAIN
Last Name:BRIDZELL
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 FOURTH STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270
Mailing Address - Country:US
Mailing Address - Phone:360-657-2755
Mailing Address - Fax:360-658-0135
Practice Address - Street 1:1606 FOURTH STREET
Practice Address - Street 2:SUITE C
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270
Practice Address - Country:US
Practice Address - Phone:360-657-2755
Practice Address - Fax:360-658-0135
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00008830225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00008830OtherSTATE DEPT HEALTH