Provider Demographics
NPI:1659427805
Name:MATTESON, SUSAN (LMP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MATTESON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 TOE JAM HILL RD NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-2382
Mailing Address - Country:US
Mailing Address - Phone:206-855-0729
Mailing Address - Fax:
Practice Address - Street 1:213 MADISON AVE N
Practice Address - Street 2:SUITE 500
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1880
Practice Address - Country:US
Practice Address - Phone:206-855-0729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015534225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00015534OtherMASSAGE PRACT. LICENSE
20-2399197OtherEIN