=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306660915
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN JEAN VANDEWALLE LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2024
-----------------------------------------------------
Last Update Date | 11/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 N 3RD ST
-----------------------------------------------------
City | MARQUETTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49855-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-869-4246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 E HEWITT AVE
-----------------------------------------------------
City | MARQUETTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49855-3715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-869-4246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 7501000087
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------