Provider Demographics
NPI:1205003365
Name:DORMAN, SUSAN ELIZABETH (RPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:DORMAN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1707
Mailing Address - Country:US
Mailing Address - Phone:860-536-6070
Mailing Address - Fax:860-536-9480
Practice Address - Street 1:475 HIGH ST
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1707
Practice Address - Country:US
Practice Address - Phone:860-536-6070
Practice Address - Fax:860-536-9480
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist