Healthcare Provider Details

I. General information

NPI: 1114297702
Provider Name (Legal Business Name): SUSAN FAITH CAPOEMAN OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 ST HELENS AVE
TACOMA WA
98402-2514
US

IV. Provider business mailing address

25611 68TH AVE E
GRAHAM WA
98338-8330
US

V. Phone/Fax

Practice location:
  • Phone: 423-647-5226
  • Fax:
Mailing address:
  • Phone: 423-647-5226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60258497
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: