Provider Demographics
NPI:1679502652
Name:DEWILDE, SUZANNE M (MPT)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:DEWILDE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1188
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 HICKORY ST NW
Practice Address - Street 2:STE. 201
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1700
Practice Address - Country:US
Practice Address - Phone:541-812-5840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist