Provider Demographics
NPI:1982077822
Name:WALDREP, SUZANNE (LMT, MMP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:WALDREP
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 WESTHOFF CT
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77384-3366
Mailing Address - Country:US
Mailing Address - Phone:832-928-6049
Mailing Address - Fax:
Practice Address - Street 1:33300 EGYPT LN
Practice Address - Street 2:SUITE I-120
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-2739
Practice Address - Country:US
Practice Address - Phone:832-914-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-31
Last Update Date:2015-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT103880225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist