Provider Demographics
NPI:1700187986
Name:DAHL, SUSAN MAE (LMT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MAE
Last Name:DAHL
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 1:8495 SW HEMLOCK STREET
Mailing Address - Street 2:UNITE E
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5837
Mailing Address - Country:US
Mailing Address - Phone:503-707-1434
Mailing Address - Fax:
Practice Address - Street 1:8495 SW HEMLOCK STREET
Practice Address - Street 2:UNITE E
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-5837
Practice Address - Country:US
Practice Address - Phone:503-707-1434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5541225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist