Provider Demographics
NPI:1497009765
Name:DE SHAZER, SUSAN KATHERINE ANNE (LMT, CLT, MLD)
Entity type:Individual
Prefix:
First Name:SUSAN KATHERINE
Middle Name:ANNE
Last Name:DE SHAZER
Suffix:
Gender:F
Credentials:LMT, CLT, MLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-4933
Mailing Address - Country:US
Mailing Address - Phone:262-365-8958
Mailing Address - Fax:
Practice Address - Street 1:608 NORTH AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-4933
Practice Address - Country:US
Practice Address - Phone:262-365-8958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11297-146174400000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist