Healthcare Provider Details

I. General information

NPI: 1073842811
Provider Name (Legal Business Name): SUSAN MAYO P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2009
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N CURTIS RD
BOISE ID
83706-1338
US

IV. Provider business mailing address

3344 S GEKELER LN APT M106
BOISE ID
83706-5268
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-3315
  • Fax:
Mailing address:
  • Phone: 209-304-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-403
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: