Provider Demographics
NPI:1679804074
Name:ANDERSON, SUSAN C
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:ANDERSON
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 1:4103 BOARDWALK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5931
Mailing Address - Country:US
Mailing Address - Phone:970-204-0400
Mailing Address - Fax:970-377-1082
Practice Address - Street 1:4103 BOARDWALK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5931
Practice Address - Country:US
Practice Address - Phone:970-204-0400
Practice Address - Fax:970-377-1082
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7337172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist