Provider Demographics
NPI:1245460633
Name:AMES-LILLIE, SUSAN K (NCTMB)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:AMES-LILLIE
Suffix:
Gender:F
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1397 270TH AVE
Mailing Address - Street 2:PO BOX 602
Mailing Address - City:LUCK
Mailing Address - State:WI
Mailing Address - Zip Code:54853-4105
Mailing Address - Country:US
Mailing Address - Phone:715-472-4181
Mailing Address - Fax:
Practice Address - Street 1:15 2ND AVE
Practice Address - Street 2:
Practice Address - City:LUCK
Practice Address - State:WI
Practice Address - Zip Code:54853-4105
Practice Address - Country:US
Practice Address - Phone:715-472-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2273-046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist