Provider Demographics
NPI:1033197793
Name:VINICOR, SUSAN DRISCOLE (PT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:DRISCOLE
Last Name:VINICOR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 N KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2156
Mailing Address - Country:US
Mailing Address - Phone:317-257-2225
Mailing Address - Fax:317-257-0646
Practice Address - Street 1:6301 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2156
Practice Address - Country:US
Practice Address - Phone:317-257-2225
Practice Address - Fax:317-257-0646
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05000347A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5995528OtherAETNA
IN000000182806OtherANTHEM BC/BS
IN000000182806OtherANTHEM BC/BS