Provider Demographics
NPI:1386932085
Name:MALL, SUSAN REBECCA (LAC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:REBECCA
Last Name:MALL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5336 NE AINSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2316
Mailing Address - Country:US
Mailing Address - Phone:503-407-0397
Mailing Address - Fax:
Practice Address - Street 1:110 E COLUMBIA RIVER HWY
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060-2068
Practice Address - Country:US
Practice Address - Phone:503-407-0397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00329171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist