Provider Demographics
NPI:1114450491
Name:MOSS, SUSAN MARIE (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:MOSS
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 1:7923 MUNSON RD
Mailing Address - Street 2:
Mailing Address - City:MENTOR ON THE LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44060-3742
Mailing Address - Country:US
Mailing Address - Phone:440-209-1836
Mailing Address - Fax:440-209-1840
Practice Address - Street 1:2899 HUBBARD RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-2933
Practice Address - Country:US
Practice Address - Phone:440-428-0422
Practice Address - Fax:440-428-0553
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04635225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist