Provider Demographics
NPI:1992998710
Name:GIBBONS, SUSAN MAE (DPT)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MAE
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:MAE
Other - Last Name:CHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-4896
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:501 SE 172ND AVE STE 110
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1773
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60448842225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2094452Medicaid