Provider Demographics
NPI:1457070765
Name:DETWEILER, SUSAN (MOTR/L)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DETWEILER
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-0129
Mailing Address - Country:US
Mailing Address - Phone:208-354-3128
Mailing Address - Fax:
Practice Address - Street 1:180 S. MAIN ST
Practice Address - Street 2:C-2, BROULIM'S RETAIL CENTER
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-0129
Practice Address - Country:US
Practice Address - Phone:208-354-3128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2623225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist