Provider Demographics
NPI:1801544028
Name:REYNOLDS, SUSANNA CROMWELL (LMP)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:CROMWELL
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:CROMWELL
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:HANDLE PRACTITIONER
Mailing Address - Street 1:4610 48TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-1456
Mailing Address - Country:US
Mailing Address - Phone:206-657-7147
Mailing Address - Fax:
Practice Address - Street 1:4610 48TH AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-1456
Practice Address - Country:US
Practice Address - Phone:206-657-7147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00019914225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist