Provider Demographics
NPI:1386066850
Name:NILES, SUSAN (MSE, ATC, LAT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:NILES
Suffix:
Gender:F
Credentials:MSE, ATC, LAT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:STROMBLAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSE, ATC, LAT
Mailing Address - Street 1:17022 HILL VIEW LN
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-4536
Mailing Address - Country:US
Mailing Address - Phone:281-736-5563
Mailing Address - Fax:
Practice Address - Street 1:19428 I-45 NORTH
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77373
Practice Address - Country:US
Practice Address - Phone:281-891-7084
Practice Address - Fax:281-891-7082
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT37652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer