Provider Demographics
NPI:1891823977
Name:HUSTAD, WENDY SUSANNE (LMT)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:SUSANNE
Last Name:HUSTAD
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 1:10114 SE KNIGHT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-4414
Mailing Address - Country:US
Mailing Address - Phone:971-506-7237
Mailing Address - Fax:
Practice Address - Street 1:1217 NE BURNSIDE RD
Practice Address - Street 2:SUITE 502
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-6722
Practice Address - Country:US
Practice Address - Phone:503-492-3910
Practice Address - Fax:503-492-3905
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10361174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist