Provider Demographics
NPI:1689826422
Name:MIX, SUSAN FLORENCE (LMT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:FLORENCE
Last Name:MIX
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 1:48 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01566-1284
Mailing Address - Country:US
Mailing Address - Phone:508-612-5545
Mailing Address - Fax:508-347-7576
Practice Address - Street 1:48 MAIN ST
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566-1284
Practice Address - Country:US
Practice Address - Phone:508-612-5545
Practice Address - Fax:508-347-7576
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3703225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist