Provider Demographics
NPI:1881883361
Name:MITCHELL, SUSAN MARIE (MT MP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MT MP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:FOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18805 SE MCGILLVRAY
Mailing Address - Street 2:103-711
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683
Mailing Address - Country:US
Mailing Address - Phone:360-448-8233
Mailing Address - Fax:360-449-3197
Practice Address - Street 1:120 NE 117TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:360-448-8233
Practice Address - Fax:360-449-3197
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023102225700000X
OR13497225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist