MEDICARE: MS. SUSAN DORENE FISHER OT ASST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant		WA

General Provider Information

NPI Number	:	1578746830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN DORENE FISHER OT ASST

Provider Business Mailing Address
First Line	:	PO BOX 337
Second Line	:
City	:	MEDICAL LAKE
State	:	WA
Zip	:	99022
Country	:	US
Telephone Number	:	509-299-6488
Fax Number	:

Provider Business Practice Location Address
First Line	:	2219 N 6TH ST
Second Line	:
City	:	CHENEY
State	:	WA
Zip	:	99004
Country	:	US
Telephone Number	:	509-235-6196
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2007
Last Update Date	:	12/10/2007

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