Provider Demographics
NPI:1750493813
Name:KNOTTS, SUSAN DIANE (PT LMT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:DIANE
Last Name:KNOTTS
Suffix:
Gender:F
Credentials:PT LMT
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:DIANE
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:27025 TRASK RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-0433
Mailing Address - Country:US
Mailing Address - Phone:503-842-7305
Mailing Address - Fax:503-842-0447
Practice Address - Street 1:27025 TRASK RIVER ROAD
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-0433
Practice Address - Country:US
Practice Address - Phone:503-842-7305
Practice Address - Fax:503-842-0447
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1387225100000X
OR1696225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR838547001OtherBCBS
OR182803Medicaid
OR320438201OtherPREF CHOICE 65 BCBS
OR838546001OtherBCBS
OR115OR00690OtherTRICARE
OR115OR00690OtherTRICARE