Provider Demographics
NPI:1952700551
Name:SUSINGER, GREGORY (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:SUSINGER
Suffix:
Gender:M
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24060 SE KENT- KANGLEY RD ST D100
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038
Mailing Address - Country:US
Mailing Address - Phone:425-433-0123
Mailing Address - Fax:425-433-0733
Practice Address - Street 1:1040 STEVENSON AVE
Practice Address - Street 2:STE A
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2991
Practice Address - Country:US
Practice Address - Phone:360-825-7411
Practice Address - Fax:360-825-7434
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60471513133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered