Provider Demographics
NPI:1912530148
Name:MACKEY, SUSAN DIANE (LMT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:DIANE
Last Name:MACKEY
Suffix:
Gender:F
Credentials:LMT
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 2578
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43571-0578
Mailing Address - Country:US
Mailing Address - Phone:419-340-2704
Mailing Address - Fax:
Practice Address - Street 1:5810 SOUTHWYCK BLVD STE 100E
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1514
Practice Address - Country:US
Practice Address - Phone:419-340-2704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-03-05
Deactivation Date:2020-02-20
Deactivation Code:
Reactivation Date:2020-03-05
Provider Licenses
StateLicense IDTaxonomies
OH33.015285225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist