Provider Demographics
NPI:1093921256
Name:BERARD, SUSAN K (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:BERARD
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:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:DILL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73641-0111
Mailing Address - Country:US
Mailing Address - Phone:580-450-2500
Mailing Address - Fax:
Practice Address - Street 1:405 E. 10TH
Practice Address - Street 2:
Practice Address - City:DILL CITY
Practice Address - State:OK
Practice Address - Zip Code:73641-0111
Practice Address - Country:US
Practice Address - Phone:580-450-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPT2941OtherPHYSICAL THERAPY LICENSE