Provider Demographics
NPI:1982975157
Name:SUSBAUER, ALEX (LMT, BCSI (CM))
Entity Type:Individual
Prefix:MR
First Name:ALEX
Middle Name:
Last Name:SUSBAUER
Suffix:
Gender:M
Credentials:LMT, BCSI (CM)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 SE 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-4103
Mailing Address - Country:US
Mailing Address - Phone:503-201-9449
Mailing Address - Fax:503-777-6077
Practice Address - Street 1:2135 SE 76TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-4103
Practice Address - Country:US
Practice Address - Phone:503-201-9449
Practice Address - Fax:503-777-6077
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8205225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist