Healthcare Provider Details

I. General information

NPI: 1750493813
Provider Name (Legal Business Name): SUSAN DIANE KNOTTS PT LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN DIANE PETERS PT

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27025 TRASK RIVER ROAD
TILLAMOOK OR
97141-0433
US

IV. Provider business mailing address

27025 TRASK RIVER ROAD
TILLAMOOK OR
97141-0433
US

V. Phone/Fax

Practice location:
  • Phone: 503-842-7305
  • Fax: 503-842-0447
Mailing address:
  • Phone: 503-842-7305
  • Fax: 503-842-0447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1387
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1696
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: