Provider Demographics
NPI:1801352570
Name:GROOM, SUSANNA (LMT)
Entity type:Individual
Prefix:MS
First Name:SUSANNA
Middle Name:
Last Name:GROOM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:D
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2435 YORK ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-1953
Mailing Address - Country:US
Mailing Address - Phone:541-683-9517
Mailing Address - Fax:
Practice Address - Street 1:155 W A ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4516
Practice Address - Country:US
Practice Address - Phone:541-747-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24975225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist