Healthcare Provider Details

I. General information

NPI: 1154315968
Provider Name (Legal Business Name): ALICIA D SUSILLA BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BROADWAY ST
LONGVIEW WA
98632-3256
US

IV. Provider business mailing address

PO BOX 249
LONGVIEW WA
98632-7154
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-2200
  • Fax: 360-414-2210
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI00001601
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: