Provider Demographics
NPI:1184968752
Name:REYNOLDS, SUSAN MARIE (LMP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:REYNOLDS
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 1:1003 E TRENT AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202
Mailing Address - Country:US
Mailing Address - Phone:509-688-6700
Mailing Address - Fax:509-688-6777
Practice Address - Street 1:3010 S. SOUTHEAST BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223
Practice Address - Country:US
Practice Address - Phone:509-688-6710
Practice Address - Fax:503-533-1838
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014359225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7123151Medicaid
WA7123151Medicaid