Provider Demographics
NPI:1700860079
Name:CULBERTSON-HOLMES, SUSAN ELIZABETH (OT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:CULBERTSON-HOLMES
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ELIZABETH
Other - Last Name:CULBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:1315 NW 4TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1328
Practice Address - Country:US
Practice Address - Phone:541-923-7494
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR983735225X00000X
WAOT00002842225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298881Medicaid
OR298881Medicaid