Healthcare Provider Details

I. General information

NPI: 1083656680
Provider Name (Legal Business Name): SUSAN IRENE WEST OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN IRENE FULTS OT

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 BLACK HILLS AVE
ALLIANCE NE
69301-3243
US

IV. Provider business mailing address

407 BLACK HILLS AVE
ALLIANCE NE
69301-3243
US

V. Phone/Fax

Practice location:
  • Phone: 308-762-6564
  • Fax: 308-762-3747
Mailing address:
  • Phone: 308-762-6564
  • Fax: 308-762-3747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number689
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: