Provider Demographics
NPI:1952323313
Name:THEISEN, SUSAN LYNN (LAT,ATC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LYNN
Last Name:THEISEN
Suffix:
Gender:F
Credentials:LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 4TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DYERSVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52040-2111
Mailing Address - Country:US
Mailing Address - Phone:563-875-9405
Mailing Address - Fax:
Practice Address - Street 1:814 4TH AVE SE
Practice Address - Street 2:
Practice Address - City:DYERSVILLE
Practice Address - State:IA
Practice Address - Zip Code:52040-2111
Practice Address - Country:US
Practice Address - Phone:563-875-9405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer