Basic Information
| Provider Information | |||||||||
| NPI: | 1467706978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEGGE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | P.T.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAKKEN | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | P.T.A. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065200 | ||||||||
| FaxNumber: | 9712065203 | ||||||||
| Practice Location | |||||||||
| Address1: | 197 SOUTH WILLARD | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286345548 | ||||||||
| FaxNumber: | 9712065203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2012 | ||||||||
| LastUpdateDate: | 11/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 0128A | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.