Provider Demographics
NPI:1245536465
Name:BURNS, SUSIE (LMT, NKT)
Entity type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:LMT, NKT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 NE REVERE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4059
Mailing Address - Country:US
Mailing Address - Phone:541-550-6680
Mailing Address - Fax:
Practice Address - Street 1:369 NE REVERE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4059
Practice Address - Country:US
Practice Address - Phone:541-550-6680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-04
Last Update Date:2011-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16722225700000X, 226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR836868OtherASSOCIATED BODYWORK & MASSAGE PEOFESSIONALS
OR16722OtherOREGON BOARD OF MASSAGE THERAPISTS