Provider Demographics
NPI:1801198924
Name:EVANS, SUSAN GAIL (LMP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:GAIL
Last Name:EVANS
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 1:3813 T ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-2564
Mailing Address - Country:US
Mailing Address - Phone:360-694-5577
Mailing Address - Fax:
Practice Address - Street 1:210 WEST EVERGREEN ELITE MUSCULAR THERAPY
Practice Address - Street 2:SUITE 500
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660
Practice Address - Country:US
Practice Address - Phone:360-693-3863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60107220225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist