Provider Demographics
NPI:1679611743
Name:REILY, SUSAN ELIZABETH (RCP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:REILY
Suffix:
Gender:F
Credentials:RCP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ELIZABETH
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 N 4TH ST
Mailing Address - Street 2:APT 130
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-7843
Mailing Address - Country:US
Mailing Address - Phone:928-380-8773
Mailing Address - Fax:
Practice Address - Street 1:167 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-2501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7626225B00000X, 2278E0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278E0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedEmergency Care
No225B00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPulmonary Function Technologist