Basic Information
| Provider Information | |||||||||
| NPI: | 1871524298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIRD | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | OTR, PA-C, LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25117 SW PARKWAY AVE STE D | ||||||||
| Address2: | |||||||||
| City: | WILSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970709697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712554079 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3203 N 15TH ST | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815065263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702440759 | ||||||||
| FaxNumber: | 8667289636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/15/2021 | ||||||||
| NPIReactivationDate: | 02/11/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9104022 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 225XP0019X | 0000738 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 11282851 | 05 | CO | MEDICAID |