Provider Demographics
NPI:1699057471
Name:BLACK, SUZANNE ELIZABETH (LMT)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:BLACK
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 1:11565 SW DURHAM RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3553
Mailing Address - Country:US
Mailing Address - Phone:503-639-0778
Mailing Address - Fax:503-639-0815
Practice Address - Street 1:11565 SW DURHAM RD
Practice Address - Street 2:SUITE 110
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-3553
Practice Address - Country:US
Practice Address - Phone:503-639-0778
Practice Address - Fax:503-639-0815
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18504174400000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist