Provider Demographics
NPI:1891362232
Name:PRINS, SUSAN M (LMT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:PRINS
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 1:186 EL VALLE RD
Mailing Address - Street 2:
Mailing Address - City:CHAMISAL
Mailing Address - State:NM
Mailing Address - Zip Code:87521-4018
Mailing Address - Country:US
Mailing Address - Phone:505-901-1272
Mailing Address - Fax:
Practice Address - Street 1:219 NM-75
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:NM
Practice Address - Zip Code:87527
Practice Address - Country:US
Practice Address - Phone:505-901-1272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT8460225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist