Provider Demographics
NPI:1154507655
Name:SMITH, SUSAN DIANE (PT, NCMT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT, NCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1826 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:BAILEY
Mailing Address - State:CO
Mailing Address - Zip Code:80421-1212
Mailing Address - Country:US
Mailing Address - Phone:303-816-4494
Mailing Address - Fax:303-816-4494
Practice Address - Street 1:1262 BERGEN PKWY UNIT E10
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-9546
Practice Address - Country:US
Practice Address - Phone:303-674-7889
Practice Address - Fax:303-674-8117
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO82992251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO801120Medicare PIN