MEDICARE: SUSAN HOLZEM OREGON LMT 20284

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172M00000X	Mechanotherapist	20284	OR

General Provider Information

NPI Number	:	1578012985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN HOLZEM OREGON LMT 20284

Provider Business Mailing Address
First Line	:	6327 SE 63RD AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-6607
Country	:	US
Telephone Number	:	503-839-6259
Fax Number	:

Provider Business Practice Location Address
First Line	:	2505 SE 11TH AVE
Second Line	:	SUITE 218
City	:	PORTLAND
State	:	OR
Zip	:	97202-1061
Country	:	US
Telephone Number	:	503-839-6259
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2016
Last Update Date	:	09/26/2016

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