Provider Demographics
NPI:1316499916
Name:BURROUGHS, SUSANNETTE (MS ED, BCMTB)
Entity type:Individual
Prefix:MISS
First Name:SUSANNETTE
Middle Name:
Last Name:BURROUGHS
Suffix:
Gender:F
Credentials:MS ED, BCMTB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GLEN EDEN AVE # 6
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-4316
Mailing Address - Country:US
Mailing Address - Phone:510-328-3679
Mailing Address - Fax:
Practice Address - Street 1:922 1/2 ROSE AVE
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:CA
Practice Address - Zip Code:94611-4342
Practice Address - Country:US
Practice Address - Phone:650-919-3054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-29
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71956172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist