Healthcare Provider Details

I. General information

NPI: 1982771010
Provider Name (Legal Business Name): SUZANNE MAE LEWIS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUZANNE MAE WHEATLY PT

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 JEFFERSON AVE SUITE B-1
ENUMCLAW WA
98022-3649
US

IV. Provider business mailing address

28700 SE 462ND PL
ENUMCLAW WA
98022-9318
US

V. Phone/Fax

Practice location:
  • Phone: 360-802-0244
  • Fax: 866-584-9044
Mailing address:
  • Phone: 360-802-0244
  • Fax: 866-584-9044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00003760
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0169982
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerL&I

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: