Provider Demographics
NPI:1700510021
Name:MCLOUGHLIN, SUSAN CONNOR
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CONNOR
Last Name:MCLOUGHLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5020
Mailing Address - Country:US
Mailing Address - Phone:707-695-7518
Mailing Address - Fax:
Practice Address - Street 1:653 CHARLES ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5020
Practice Address - Country:US
Practice Address - Phone:707-695-7518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18375225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist