Provider Demographics
NPI:1245392489
Name:PETERS, SUSAN M (PT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:PETERS
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 1:734 N ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1728
Mailing Address - Country:US
Mailing Address - Phone:708-386-5019
Mailing Address - Fax:
Practice Address - Street 1:345 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-2109
Practice Address - Country:US
Practice Address - Phone:708-488-0072
Practice Address - Fax:708-488-0084
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070006345225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist