Provider Demographics
NPI:1750490538
Name:MACK, SUSAN M (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 INDIAN SUMMER DR SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-4770
Mailing Address - Country:US
Mailing Address - Phone:360-456-1945
Mailing Address - Fax:
Practice Address - Street 1:1830 112TH ST E
Practice Address - Street 2:STE D
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98445-3747
Practice Address - Country:US
Practice Address - Phone:253-548-8400
Practice Address - Fax:253-537-3150
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006329225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist