Healthcare Provider Details

I. General information

NPI: 1801198924
Provider Name (Legal Business Name): SUSAN GAIL EVANS LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WEST EVERGREEN ELITE MUSCULAR THERAPY SUITE 500
VANCOUVER WA
98660
US

IV. Provider business mailing address

3813 T ST
VANCOUVER WA
98663-2564
US

V. Phone/Fax

Practice location:
  • Phone: 360-693-3863
  • Fax:
Mailing address:
  • Phone: 360-694-5577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60107220
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: