Provider Demographics
NPI:1114792777
Name:FRASER, SUSAN J (PTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:FRASER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:CASALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:62 BOULDIN RD
Mailing Address - Street 2:
Mailing Address - City:CHARLES TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25414-5668
Mailing Address - Country:US
Mailing Address - Phone:315-212-3637
Mailing Address - Fax:
Practice Address - Street 1:1263 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-4384
Practice Address - Country:US
Practice Address - Phone:304-725-6575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002052225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant