Provider Demographics
NPI:1124410519
Name:VAN DER WALT, SUSANNA (SUNEL) P (DPT)
Entity Type:Individual
Prefix:DR
First Name:SUSANNA (SUNEL)
Middle Name:P
Last Name:VAN DER WALT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 ANASAZI TRAILS LOOP
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-8760
Mailing Address - Country:US
Mailing Address - Phone:505-639-9937
Mailing Address - Fax:
Practice Address - Street 1:5700 HARPER DR NE STE 250
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3588
Practice Address - Country:US
Practice Address - Phone:505-828-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM45942251X0800X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10171568Medicaid
NM326556OtherMEDICARE