Provider Demographics
NPI:1306435045
Name:TVEIT-VICKSTROM, SUSAN JOY (CMT, BTAA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JOY
Last Name:TVEIT-VICKSTROM
Suffix:
Gender:F
Credentials:CMT, BTAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 ELDERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-2177
Mailing Address - Country:US
Mailing Address - Phone:559-924-9007
Mailing Address - Fax:
Practice Address - Street 1:1613 S DOLLNER ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-4530
Practice Address - Country:US
Practice Address - Phone:559-816-4938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-17
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABL017632225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist