Healthcare Provider Details

I. General information

NPI: 1306435045
Provider Name (Legal Business Name): SUSAN JOY TVEIT-VICKSTROM CMT, BTAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2021
Last Update Date: 01/17/2021
Certification Date: 01/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 S DOLLNER ST
VISALIA CA
93277-4530
US

IV. Provider business mailing address

734 ELDERWOOD LN
LEMOORE CA
93245-2177
US

V. Phone/Fax

Practice location:
  • Phone: 559-816-4938
  • Fax:
Mailing address:
  • Phone: 559-924-9007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberBL017632
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: