Provider Demographics
NPI:1124530282
Name:RAY, SUSAN MICHELE (LMT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MICHELE
Last Name:RAY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 W SPRINGFIELD AVE STE E
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2979
Mailing Address - Country:US
Mailing Address - Phone:217-819-2155
Mailing Address - Fax:
Practice Address - Street 1:2106 W SPRINGFIELD AVE STE E
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2979
Practice Address - Country:US
Practice Address - Phone:217-819-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227016138225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist