Provider Demographics
NPI:1215005772
Name:LAGEMANN, SUSAN JANE (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:LAGEMANN
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 1:19538 PIKE 266
Mailing Address - Street 2:
Mailing Address - City:EOLIA
Mailing Address - State:MO
Mailing Address - Zip Code:63344-4014
Mailing Address - Country:US
Mailing Address - Phone:573-485-6316
Mailing Address - Fax:573-485-6316
Practice Address - Street 1:19538 PIKE 266
Practice Address - Street 2:
Practice Address - City:EOLIA
Practice Address - State:MO
Practice Address - Zip Code:63344-4014
Practice Address - Country:US
Practice Address - Phone:573-485-6316
Practice Address - Fax:573-485-6316
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPT109456225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist